MossRehab has long recognized that research plays a critical role in driving the innovations that are needed to advance the field of rehabilitation. With this recognition in mind, the Moss Rehabilitation Research Institute (MRRI) was founded in 1992. Since then, under the direction of John Whyte, MD, PhD, the institute has sponsored interdisciplinary research aimed at improving human function and adaptation to disability. Recently, Dr. Whyte sat down with writer Susan Worley to discuss current developments and new directions at MRRI, in addition to his research.
MRRI recently updated its mission. Could you talk a little about this change in focus?
Dr. Whyte: We recently shifted our mission from, 'Foster theoretically motivated rehabilitation research focused on issues relevant to human function' to 'theory driven research to clinical treatments in neurorehabilitation.' This isn’t really a change in our focus, but simply a better way of explaining what sets us apart. During the past few years, there has been much discussion about translational research—the process of taking basic scientific discoveries and transforming them into practical diagnostic assessments and clinically useful treatments. There is widespread concern that although we invest a lot of national resources in basic scientific research, the impact of that research on human health is very slow in coming or never materializes.
What is MRRI’s response to this problem?
Dr. Whyte: We are aware that some researchers who study, for example, particular body systems or scientific technologies, may not fully understand the clinical needs of patients who might benefit from their discoveries. And we know that other researchers, who are very familiar with patient needs, may not have a sophisticated understanding of the scientific domains that are relevant to a particular patient population. At MRRI, we have made a concerted effort to recruit and hire scientists across the spectrum, and to facilitate an ongoing collaboration among them. We also offer career development training to both basic scientists and clinicians, in which translational work is not just discussed but modeled every day.
What are some of your immediate and long-range goals?
Dr. Whyte: One of our key short-term goals is recruitment. We are currently hiring scientists in several areas within our cognitive and movement science programs, with the aim of expanding our scientific staff and increasing the range of skills represented among our investigators. We are also exploring ways to increase our collaborative relationships with area universities, who are eager for support in translating their own scientific work into clinically meaningful directions. In the long run, we seek to test a range of new theory-based assessments and treatments, to determine their utility and effectiveness. As we begin to identify more rehabilitation treatments that are effective, we find it is increasingly important to ask: “effective for whom?” Many rehabilitation treatments are not suited to everyone. MRRI is uniquely positioned to conduct research that helps link varied patients with the treatments that are most effective for them. Our large patient base and our use of theory-based measures to categorize our research participants are helping us to achieve this important task.
Last year MRRI received an award from the Patient-Centered Outcomes Research Institute (PCORI). Could you talk a little bit about PCORI and explain how this type of award differs from, for example, an NIH grant?
Dr. Whyte: PCORI is an organization that was launched as part of the Affordable Care Act (ACA). As a funding agency, it differs from others because it is solely focused on patient-centered comparative effectiveness research (CER). Unlike NIH, which often supports basic research—that is, research that aims to discover how things work—PCORI’s main mission is to learn the best way to approach or treat specific real-world problems. All of the research that PCORI funds is patient-centered, which means that it is designed to help patients and their families and clinicians make important health care decisions. PCORI also offers special awards under a methodology subprogram. These awards support the development of methods that will make it easier to answer important patient-centered questions in the future. We received an award to conduct methodological research.
What methodological problem did you set out to address?
Dr. Whyte: We have become increasingly aware that it’s really difficult to do comparative effectiveness research in most areas of rehabilitation without a clear definition of treatments. CER implies that you are comparing treatment A with treatment B; however, if you don’t have a good definition of treatment A or treatment B, a scientifically valid comparison is impossible. Even when it is possible to determine that one treatment is better, it is challenging to share the best treatment with other clinicians, without knowing precisely what it is about a particular treatment that must be passed on. Among the special problems in rehabilitation that require research, this one ranks among the biggest, because it affects every aspect of rehabilitative care.
Is MRRI the first research institute to examine this problem?
Dr. Whyte: The first step in the process of examining this problem took place more than six years ago, and it’s important to mention that we began our work in collaboration with Marcel Dijkers, PhD, and other colleagues at the Icahn School of Medicine at Mount Sinai in New York. Our initial work began under a National Institute on Disability and Rehabilitation Research (NIDRR) grant, with Dr. Dijkers as lead investigator. The PCORI grant has provided us with funding that will allow us to continue this important work. It would be correct to say that, together with our colleagues, we are leaders in this area of research.
Your research is focused on the development of a treatment taxonomy. Could you explain what that is?
Dr. Whyte: A taxonomy refers to a way of categorizing things. Rehabilitative treatments are already categorized in a number of different ways. One form of treatment may be described as physical therapy, while another may be described as occupational therapy–that’s a taxonomy. Or, we frequently make a distinction between inpatient rehabilitation and outpatient rehabilitation–that’s a taxonomy. One treatment may be called gait training, while another is called memory remediation—that’s a taxonomy. The problem with all of these categories is that they don’t help to define treatments in ways that can be directly linked to their efficacy and effectiveness. It doesn’t do us any good to simply say someone had physical therapy, if we don’t know precisely what was done during a therapy session, or precisely how it was done.
Could you give an example?
Dr. Whyte: Let’s consider a therapy that we refer to as memory remediation, and suppose we ask this question: is memory remediation effective? If we begin to explore this problem, the first thing we’ll find is that many different treatments are called memory remediation. One of these might involve training patients to use a notebook to keep track of things. Another might involve repetitive exercises that are designed to help strengthen the memory network in the brain. Another treatment might involve using a digital pager that is programmed to go off to remind a patient to perform certain tasks. If we carefully examine each of these treatments, we might find that using a notebook to keep track of things is effective, whereas we might find that repetitive exercises are ineffective. But it doesn’t make sense for us to group all of the treatments together under the heading of memory remediation, and say whether we think memory remediation is effective. Simply talking about memory remediation is not useful because it does not give us enough detail about the therapy.
Are you trying to come up with better descriptions of treatments?
Dr. Whyte: We are focused on describing any treatment in terms of three fundamental components. These are 1) the essential ingredient; 2) the target of treatment; and 3) the mechanism of action (MOA), which links the essential ingredient(s) to the target. When we talk about any treatment, we want to be able to say why and how the essential ingredients of the treatment worked to change the target of treatment.
Why is it important to describe rehabilitative treatments in terms of these components?
Dr. Whyte: With many mainstream medical treatments, such as those involving drugs or surgery, the active ingredients are obvious. When a patient takes a drug, we know the active ingredients are the chemicals in a pill. The active ingredients of a surgical procedure are also usually straightforward–we know that to repair something during surgery, it’s necessary to connect one part of the body to another, for example.
But when a physical therapist asks a patient to undergo gait training, it’s much more difficult to identify the essential ingredients of the therapy. Therefore, it’s difficult to identify how and why a therapy such as gait training works. Is it the amount of walking a patient does during a session that makes the therapy successful? Is it the specific set of cues that a therapist uses to correct a patient’s gait? Is it the degree of support, or lack of support, that the therapist offers while the patient is walking?
As with treatments involving drugs or surgery, it is necessary to isolate the essential ingredients of rehabilitative treatments and determine exactly how and why the ingredients are used to change a target of treatment. If we can do this, then we can compare treatments in a scientifically valid way–just as we do when we compare pharmaceutical treatments, for example. We also will be able to facilitate communication among clinicians in a way that lets them know which treatments work and which don’t work, and that also lets clinicians know precisely what is meant by any given treatment.
How will a rehabilitative treatment taxonomy benefit patients?
Dr. Whyte: With a successful rehabilitative treatment taxonomy, we will be able to determine which treatments are of greatest value for patients, and just as important, we will be able to clearly communicate to all clinicians exactly what these treatments are and exactly how they are performed. Eventually it will be possible to compare treatments around the world, and communicate which of these are best to different countries. In fact, an international classification of health care interventions (known as ICHI) is currently being developed by the World Health Organization. We hope that findings from our research will help to inform the classification of rehabilitative treatments under this system.