Using the Rehabilitation Treatment Specification System (RTSS) to Maximize Rehabilitation Research Impact: A Video-Based Observational Study
Conditions: Stroke, Spinal Cord Injury, Occupational Therapy
Sponsor: Ohio State University

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Research Protocol 
 
Title: Using the Rehabilitation Treatment Specification System (RTSS) to Maximize 
Rehabilitation Research Impact: A Video-Based Observational Study   
 
Principal Investigator: Lauren Wengerd, PhD, MS, OTR/L 
 
Funding Sponsor: American Occupational Therapy Foundation (AOTF) Implementation 
Research Grant 
 
I. 
Specific Aims  
Aim 1. Characterize the active ingredients of occupational therapy (OT) interventions used 
to treat UE sensorimotor impairment in adult stroke survivors receiving outpatient OT 
services.  
Aim 2. Characterize the active ingredients of occupational therapy (OT) interventions used 
to treat UE sensorimotor impairment in adult spinal cord injury (SCI) survivors receiving 
outpatient OT services.  
Aim 3. Develop and publish a ‘Video-Based Observation Toolkit’ to systematically 
describe OT interventions using the RTSS and principles of implementation science. 
 
II. Significance and Innovation  
A. Significance 
Stroke Rehabilitation  
Stroke remains a leading cause of long-term disability in the United States (Virani et al., 
2021). While increasingly rigorous research is being conducted to identify efficacious 
interventions, there continues to be conflicting evidence on how to best address stroke-
related upper extremity (UE) hemiparesis (Stinear, 2016). A recent systematic review on 
interventions targeting UE hemiparesis found that no experimental interventions were 
superior to ‘standard care’ control group interventions (Lin et al., 2018). While it is 
certainly possible that the experimental interventions were not superior to standard care, 
it is equally plausible that there was inadequate contrast between the treatment groups 
(Jolkkonen & Kwakkel, 2016). As a result of inadequate intervention reporting (e.g., 
using generic treatment labels, inadequate descriptions interventions) less than half of 
experimental interventions can be replicated (Hoffmann & Walker, 2015; Pino et al., 
2012). The problem is even greater for control group intervention procedures – 
commonly referred to as ‘usual care,’ ‘standard care,’ or ‘conventional therapy’ – with 
wide variation in study parameters for interventions with the same label (Borschmann et 
al., 2018; Lohse et al., 2018). The majority of stroke rehabilitation trials provide little to 
no rationale for why the control group intervention selected is comparable to standard 

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care rehabilitation (Lohse et al., 2018), which is likely due to limited literature on current 
practice patterns of OT practitioners in stroke rehabilitation. Given that stroke is the most 
treated diagnosis across all registered OT practitioners (National Board for Certification 
in Occupational Therapy (NBCOT), 2022), there is a critical and urgent need to better 
understand current practice patterns of OT practitioners in stroke rehabilitation to inform 
future directions in stroke rehabilitation research and elucidate progress and gaps in 
evidence-based practice. 
 
Previous studies investigating interventions used in stroke rehabilitation are outdated 
(Ballinger et al., 1999; Lang et al., 2009), were conducted in inpatient settings (Bode et 
al., 2004; Latham et al., 2006), or investigated practice patterns outside of the United 
States (De Weerdt et al., 2000). The proposed work is significant in that we will use the 
Rehabilitation Treatment Specification System (RTSS), a novel framework designed to 
systematically describe the ‘active ingredients’ of rehabilitation interventions (Hart et al., 
2019), to guide our analysis interventions used in real-world stroke rehabilitation 
settings. The overall purpose of this study is to investigate the types of treatment activities 
OT practitioners use to address stroke-related motor impairments in outpatient 
rehabilitation and characterize them according to the RTSS Framework. Using a 
comprehensive video observation methodology, we will identify the most frequently 
used OT intervention ingredients (e.g., time spent on task-oriented training, number of 
repetitions, modalities used, etc.) to treat adult stroke survivors with UE hemiparesis. 
This research will address AOTF’s priorities of increasing equitable access to healthcare 
services and improving health management of chronic conditions, like stroke. By 
understanding, describing, and defining ‘standard care’ for post-stroke rehabilitation 
across clinical settings, we can develop a guideline based on evidence-based practice and 
practice-based evidence that will improve the quality of care for every adult stroke 
survivor across the continuum of care. This will improve how post-stroke care is 
delivered and how novel treatment approaches are examined in the research. It will 
identify what the priority active ingredients are for the best outcomes in clinical practice. 
 
Spinal Cord Injury (SCI) Rehabilitation 
The aforementioned critical need for a better understanding of standard care in stroke 
rehabilitation is also present in SCI rehabilitation. We have an even more limited 
understanding of SCI rehabilitation interventions being used with only one known article 
published in the past five years exploring SCI interventions for UE paralysis, and said 
article only focused on one specific type of intervention, functional electrical stimulation 
(Dionne et al., 2020). Furthermore, average length of stay in inpatient rehabilitation for 
SCI patients has decreased by over 50% in the past 20 years (National Spinal Cord Injury 
Statistical Center, 2020), making the interventions administering in outpatient 

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rehabilitation even more critical for recovery. We will investigate practice patterns of OT 
practitioners treating SCI across the three practice settings to address this gap.  
 
B. Innovation 
The work outlined in this proposal is innovative in several ways. First, our group will be 
the first to incorporate the RTSS to characterize standard care in stroke or SCI 
occupational therapy. This approach will inform not only stroke research but will also 
elucidate ways OT researchers can use the RTSS in their own work to better describe 
experimental and control interventions. Additionally, this work will utilize a video-based 
observational study design to comprehensively analyze and describe intervention details 
that simply could not to be characterized using other observational methods (e.g., non-
video observation, chart reviews). There is a growing body of evidence supporting the 
use of video-based observation over traditional approaches to capture details that 
otherwise get missed (Golembiewski et al., 2023). As an example, previous work by Lang 
and colleagues (2009) published a ground-breaking paper on the number of repetitions 
stroke patients completed, on average, per treatment session. While the results of that 
work were incredibly important to the field, the methodology limited the authors to only 
counting repetitions without characterizing other intervention factors that may have had 
an influence on neurorecovery (Kleim & Jones, 2008). Non-video observation limits the 
ability to measure interrater reliability, re-watch the intervention to ensure nothing was 
missed, and capture other ‘ingredients’ of the intervention (e.g., the types of verbal cues 
provided, modalities used, patient level of engagement, etc.) that may play a critical role 
in intervention efficacy. Our approach will allow us to comprehensively describe all 
aspects of the intervention, a critical need identified in the field. This innovative research 
will help researchers 1) identify knowledge gaps and plan future directions in stroke 
rehabilitation research, 2) provide a rationale for control interventions that are 
comparable to true ‘standard care’ in stroke rehabilitation trials, and 3) develop an 
empirically based approach to video observation using the RTSS and disseminate these 
findings as a ‘toolkit’ for OT researchers to use across diagnoses and settings. 
 
C. Approach 
Preliminary Studies: Our preliminary work investigating practice patterns of OT 
practitioners in stroke rehabilitation used a mixed methods approach. First, we conducted 
a nationwide survey of outpatient OT practitioners (n=257) to identify OT interventions 
and active ingredients used to treat adult stroke survivors with UE hemiparesis in 
outpatient rehabilitation (Wengerd, 2019). In conducting this study, we found that less 
than 93% of outpatient OT practitioners consistently use clinical practice guidelines 
(CPGs) to guide stroke rehabilitation assessment and interventions. While concerning, 
we also know that CPGs in their current form are difficult to quickly digest and 
implement (Juckett et al., 2019) and several barriers exist to utilizing EBP consistently 
in practice (Juckett et al., 2019). Our preliminary survey also indicated that OT 
practitioners rank ‘techniques to increase UE use in everyday tasks,’ ‘client-centered 

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treatment,’ and ‘occupation-based treatment’ as the three most critical ‘active 
ingredients’ of stroke rehabilitation for adults with UE hemiparesis, which is largely 
consistent with OT CPG recommendations (Hildebrand et al., 2023; Wolf & Nilsen, 
2015). Additionally, we conducted a feasibility study testing a manual developed by this 
study’s PI to systematically analyze video data using the RTSS in an outpatient setting. 
We conducted this observational study in a small sample of videos (n=30) at Ohio State 
Wexner Medical Center (OSUWMC) to determine the feasibility of recruiting 
participants, collecting data efficiently, and using the RTSS to code video observations 
(Wengerd, 2019). The results of the study demonstrated that this approach to 
characterizing standard care is feasible, efficient, and did not place undue burden on 
patients or therapists during standard care OT sessions. As part of currently proposed 
project, we will take what we learned from that initial study and expand our methodology 
to be more robust in order to conduct a large-scale video analysis across 3 practice 
outpatient settings (rural, urban, and suburban) in central Ohio. We will then use our 
findings and knowledge gained from the analysis to develop a toolkit that can be used by 
OT researchers across the field to improve descriptions of OT interventions to further 
advance rehabilitation research. 
Guiding Framework: The overall guiding framework for this project is the RTSS. To 
demystify the “black box” of rehabilitation, an interprofessional team developed the 
RTSS (Hart et al., 2019) to assist rehabilitation researchers and practitioners in 
adequately characterizing treatment activities to improve replicability and interpretation 
of study results (Whyte et al., 2021). The OT field has called for use of the RTSS 
framework (Fasoli et al., 2019) along with other rehabilitation disciplines to improve 
replicability, internal validity, and our ability to conduct meta-analyses on intervention 
trials in the future (Bernhardt et al., 2019; Walker et al., 2017). According to the RTSS, 
all treatment activities (referred to as treatment components), require the characterization 
of three elements: 1) active ingredients (what is done and what materials are used to 
facilitate change), 2) a mechanism of action (the hypothesized way the ingredients will 
facilitate change), and 3) a clearly defined treatment target (what specific area of 
functioning is being addressed through use of the intervention) with accompanying 
treatment category. Characterization of treatment targets also includes describing what 
treatment category the intervention falls into: 1) Organ Function (treatments modifying 
the function of organ systems, such as strengthening muscles or improving 
cardiovascular endurance), 2) Skills and Habits (activities where learning is 
accomplished through repetitive practice), and 3) Representations (interventions 
targeting cognitive and affective information processing) (Hart et al., 2019). In addition 
to categorizing interventions by RTSS category, we will further break down the specific 
‘active ingredients’ observed of different practice approaches/theories commonly 
described in the literature (e.g., constraint-induced movement therapy, task-oriented 
training) without using generic labels. As an example, rather than labeling an intervention 
‘task-oriented training’, we will explicitly look for the ‘active ingredients’ of task-
oriented training including maximizing repetitions, using client-centered, occupation-
based activities, and providing extrinsic feedback to encourage hand use. 
 
III. Procedures 

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A. Research Design 
We will conduct a video-based observational study to assess the practice patterns of OT 
practitioners working across 3 outpatient settings at OSUWMC. Treatment sessions will be 
recorded and video data will be analyzed and coded for duration-based and frequency-based 
events using Mangold INTERACT video coding software. We will use the RTSS framework to 
guide our analyses, as described briefly in the ‘Guiding Frameworks’ section previously. 
Examples of the types of interventions we may code and analyze during OT treatment sessions 
are shown in Figure 1.  
 
Our observational study design is appropriate for our descriptive exploratory approach to 
determine the treatment activities, treatment targets, and active ingredients of OT interventions 
among OT practitioners and post-stroke patients in outpatient rehabilitation. We previously 
demonstrated this approach as feasible and wish to expand upon our initial findings to better our 
understanding of standard care and develop a toolkit which can be used across OT research 
disciplines for video observation. This methodology will be used to inform a multi-site, 
nationwide observation study in the future, much like previous groups (Lang et al., 2007, 2009). 
 
B. Sample and Recruitment 
Participants – OT practitioners 
A purposive sample of OT practitioners working in an outpatient rehabilitation at 
OSUWMC will be recruited for this study. We plan to recruit up to 15 OT practitioners 
(occupational therapists or occupational therapy assistants) across three different 
OSUWMC outpatient clinics. OSUWMC employs ~12-15 outpatient OT practitioners 
who provide services to stroke or SCI survivors on a routine (e.g., monthly) basis. We 
will record a maximum of 30 sessions per OT participant. We will make our best effort 
to evenly distribute video recordings across all therapists enrolled, however, this may 
Figure 1. Examples of rehabilitation interventions  

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vary based on the number of SCI and stroke patients seen by each therapist, number of 
therapists at each clinic location, etc.    
Inclusion Criteria: 1) must be a licensed OT practitioner (occupational therapist or 
occupational therapy assistant), 2) the OT practitioner must treat at least one adult 
stroke or spinal cord injury patient with UE sensorimotor impairment per month, 
3) the OT practitioner must be willing to be video recorded while treating their 
enrolled stroke or SCI patients.  
Participants – Stroke Patients 
A purposive sample of stroke patients receiving OT at an OSU outpatient rehabilitation 
clinic will be recruited for this study. We plan to record 90 treatment sessions across three 
practice settings. To maximize representativeness of our sample, we will not record more 
than 3 videos per stroke patient participant. As such, we plan to enroll up to 45 stroke 
patients in this study to allow for potential attrition and/or participants who do not have 
three sessions left at the time of enrollment. 
• Inclusion Criteria: 1) must have a medical diagnosis of ischemic or hemorrhagic 
stroke, 2) must be ≥ 18 years old, 3) must have at least one OT goal related to UE 
hemiparesis, 4) must have at least one remaining OT treatment session after 
enrollment, and 5) the patient’s OT must be enrolled in the study. 
Participants – Spinal Cord Injury Patients 
A purposive sample of SCI patients receiving OT at an OSU outpatient rehabilitation clinic 
will be recruited for this study. We plan to record 60 treatment sessions of SCI patients 
across three practice settings. To maximize representativeness of our sample, we will not 
record more than 3 videos per SCI patient participant. As such, we plan to enroll up to 30 
SCI patients in this study to allow for potential attrition and/or participants who do not have 
three sessions left at the time of enrollment. 
• Inclusion Criteria: 1) must have a medical diagnosis of cervical spinal cord injury, 
2) must be ≥ 18 years old, 3) must have at least one OT goal related to UE 
sensorimotor impairment, 4) must have at least one remaining OT treatment session 
after enrollment, and 5) the patient’s OT must be enrolled in the study. 
 
Recruitment and Retention 
The greatest potential problems associated with this research will include challenges with 
recruitment of OT practitioners. The PI has established great rapport with therapists 
across OSUWMC through previous studies and demonstrated the feasibility of 
conducting this work on a smaller scale. Furthermore, we have the outpatient 
neurorehabilitation manager and a senior occupational therapist across multiple sites 
aligned and committed to helping create buy-in and support for this study. To recruit OT 
practitioners, our study team will initiate contact via secure email, providing an overview 
of the study, its purpose, and procedures, along with a study flyer. We will collaborate 
with key stakeholders, such as the rehabilitation manager and OT study collaborator 
Cheryl Albrechta, to organize informational sessions, either in person or virtually, to 
accommodate participants across multiple sites. These sessions will provide an 

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opportunity to learn about the study, receive the informed consent form, and ask 
questions. For those unable to attend, individual meetings will be arranged to review 
study details and facilitate the consent process. To protect privacy, all communications 
will adhere to institutional policies, and personal information will be managed securely. 
Participants may provide consent during the informational session or in a later, private 
setting with a study team member. No identifying information will be shared outside the 
research team. Once enrolled, OT practitioners will be trained on how to recruit patient 
participants, including sharing study flyers, notifying patients verbally, and providing 
contact information for the study team. Recruitment materials may also be displayed in 
public areas of outpatient rehabilitation sites where data collection will occur (e.g., 
Martha Morehouse, New Albany, Dublin, and Powell). Patient participants will be 
introduced to the study by their OT. Interested individuals will meet with a study team 
member in a private or semi-private setting within 
the clinic to discuss the study procedures and 
review the informed consent. Formal HIPAA 
Authorization will be obtained before conducting 
medical chart reviews. We will also plan to have a 
member of our study team on site at each location 
at various times throughout the study, and therapists 
can make a direct introduction to their potential 
patient participants in real-time to support 
recruitment. This approach worked exceptionally 
well when we collected preliminary data using this 
approach and we were able to recruit 17 patient 
participants in under one month. OT participants 
will be given $25 per video recording of their 
sessions, 
up 
to 
$750 
maximum 
(30 
sessions/therapist max.). Payment will be made via 
a Greenphire ClinCard, a reloadable prepaid debit 
card, 
following 
university 
policies 
upon 
enrollment.  Stroke and SCI patients will be given 
a physical $25 gift card upon study enrollment for 
their time and willingness to be video recorded to 
enhance recruitment and retention efforts.   
 
C. 
Detailed Study Procedures 
An overview of the study flow is presented in 
Figure 2. Upon enrollment, OT participants will be 
asked to provide demographic and clinical 
characteristics using a short questionnaire. To 
confirm eligibility (medical diagnosis and OT goals) and collect pertinent medical 
information for future analyses, patient participants will be asked to provide their name, 
date of birth, hand dominance, and impaired UE (right, left, or bilateral) upon enrollment. 

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A member of our study team with access to the OSU Integrated Healthcare Information 
System (IHIS) will access patient participant medical charts to confirm diagnosis, date 
of injury, and extract relevant data from their medical chart (e.g., comorbidities, 
rehabilitation frequency/duration, rehabilitation outcomes, etc.). Data extracted from 
patient participant medical charts will be linked to the participant’s research file by 
subject ID to maintain confidentiality.  
 
Informed Consent and Confirmation of Eligibility 
Study participants will be educated on the goals of the study and review the informed 
consent form with a member of our study team. Consent will be obtained using paper 
forms (wet signature) at the location of the research (e.g., Martha Morehouse, Outpatient 
Clinic New Albany, Outpatient Clinic Dublin, Outpatient Clinic Powell,etc.) prior to 
initiation of any study procedures. After receiving study information and/or reviewing 
the consent form with potential participants, they will be made aware that they may take 
the consent form home to review and consider prior to making a decision about 
participating in the research. A copy of the consent form will be provided to the 
participant and the original copy will be stored in a secure, locked filing cabinet in Dr. 
Wengerd's lab. We will also upload a scanned copy of the consent form into REDCap for 
storage. They will be informed that participation in the study is voluntary and if they 
choose to not participate or withdraw from the study at any time, no benefits of their 
employment (OT practitioners) or medical care (patient participants) will be impacted. 
After completing the informed consent form, a member of our study team will confirm 
eligibility by reviewing the eligibility criteria checklist with both OT practitioners and 
patient participants, respectively (refer to ‘OT Eligibility Checklist’ and ‘Patient 
Eligibility Checklist’ case report forms – these forms will be entered into REDCap and 
data will be collected electronically by a member of our study team).  
 
Video Recording Procedures 
After patient participants enroll in the study, therapy schedules will be obtained from 
clinic staff to facilitate the scheduling of video recordings. Prior to recording a treatment 
session, a study team member will confirm with the OT that the session is appropriate 
for recording. Sessions are appropriate for recording if: 1) more than 50% of the session 
is anticipated to involve interventions targeting functional deficits related to UE motor 
impairment (e.g., activities of daily living involving use of the hands/arms, UE 
sensorimotor interventions, etc.); and 2) the session does not include a formal evaluation 
such as a progress report, evaluation, or discharge report (though intermittent assessment 
is allowed as this is standard practice). After confirming session appropriateness, study 
staff will be on-site to set up the video camera. Patient and OT participants will verbally 
confirm consent to be recorded prior to each recorded session. For each treatment session, 
every attempt will be made to place the video camera in a way that is both unobtrusive 
and able capture treatment activities without inadvertently capturing non-participants in 
the background. A study team member will be on-site during all video recordings, though 

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not necessarily in the treatment area, in an effort to decrease risk of participant behavior 
change (Asan & Montague, 2014).  
 
Video Recording Setup: Study team members will set up a stationary camera mounted to 
a tripod at a fixed point within the treatment area. This positioning will be carefully 
selected to face the patient and the OT without other patients/therapists in view to the 
best of our ability. In our previous study using comparable methods, the majority of 
sessions took place at a table near or against a wall without much movement around the 
clinic as therapy was focused on tabletop activities. If the therapist anticipates changing 
locations during the session they will make the study team member setting up the camera 
aware so they can monitor and adjust as needed. Additionally, we will adhere a bright 
neon sign to the video cameras stating that video recording is in progress, as well as 
verbally notify patients and therapists in the immediate vicinity that we will be recording, 
and they will have the option to verbally request that we choose an alternate spot for 
treatment/recording. In the event that other patients/therapist are recorded (e.g., walked 
into the background of the shot) we will blur faces/identifying features if the video is to 
shared outside of our study team (e.g., during a conference presentation).Of note, in our 
small feasibility study using video observation methods, we had no trouble with this 
approach, and it was tolerated well by everyone in the clinical space. Video recording 
will start when the OT and patient participant are both in the treatment area and end at 
the conclusion of the last treatment activity. No more than 3 treatment sessions per patient 
participant and no more than 30 treatment sessions per OT practitioner will be recorded 
to increase the representativeness of our sample. 
Data Collection 
• OT Demographics and Clinical Characteristics 
OT participants will be asked to provide demographic and clinical characteristics 
using a short questionnaire (refer to ‘OT Intake Questionnaire’ and ‘OT 
Demographics and Clinical Experience’ case report form). This data will be entered 
directly into REDCap by the participant using a secure survey link provided by a 
member of our study team upon enrollment.  
 
• Patient Demographics and Medical Information 
To confirm eligibility (medical diagnosis and OT goals) and collect pertinent medical 
information for future analyses, patient participants will be asked to provide their 
name and date of birth at the time of enrollment (refer to ‘Patient Intake 
Questionnaire’ case report form). This data will be entered directly into REDCap by 
a member of our study team upon enrollment. This information will be used by study 
personnel with OSU Integrated Healthcare Information System (IHIS) access to 
extract patient data from their medical chart. Data extracted from patient participant 
medical charts will be coded and linked to the participant’s research file by subject 
ID to maintain confidentiality.  
 

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Patient participants will provide HIPAA authorization with their informed consent to 
allow a member of our study team to review their medical chart and treatment notes 
and extract pertinent information for analyses. This data will include demographics 
(e.g., age, sex, gender), clinical characteristics (e.g., comorbidities, medical diagnosis 
of stroke or SCI, date of stroke or SCI diagnosis), and rehabilitation data (e.g., 
inpatient rehab length of stay, outpatient rehabilitation frequency/duration/length of 
stay, rehabilitation clinical outcomes, rehabilitation treatment notes, etc.). We will 
review treatment notes for the sessions we observe and analyze to compare our 
findings with those reported by the OT practitioner (e.g., duration of active treatment 
time, type of intervention used), as well as confirm treatment targets. Participant data 
will be coded with their subject ID stored in an access-controlled master key and all 
other records will only be linked to participants by subject ID. Data collected from 
the medical chart will be entered directly into REDCap. REDCap provides a secure, 
web-based application that provides an intuitive data manipulation interface, custom 
reporting capabilities, audit trail functionality, real-time data monitoring/querying of 
participant records, and variations of data exporting/importing to common statistical 
packages (SPSS, SAS, R, etc.). The provisioning of accounts and user access to 
specific database(s) is integrated with the OSUWMC LDAP authentication service 
for studies containing protected health information (PHI), the provisioning of access 
and specific user rights for all studies and review of content are managed by CCTS 
staff (The Ohio State University Center for Clinical and Translational Science 
(CCTS): Grants and IRB Language, n.d.). 
 
• Video and Photo Data 
All treatment sessions will be video recorded and coded electronically using Mangold 
INTERACT video analysis software to allow us to analyze both duration (e.g., time 
spent on active therapy versus rest/setup) and frequency (e.g., number of UE 
repetitions) data, as well as control for significant participant behavior change (Asan 
& Montague, 2014). An overview of the video coding framework is presented in 
Figure 3. We will make every attempt to categorize all treatment activities into these 
categories, though we may find during our analyses that a sub-category needs to be 
added (e.g., education) and it may be updated through an iterative process. The 
primary outcomes for this study are the identification of 1) the types of treatment 
activities (e.g, ‘Organ Function’ versus ‘Skills and Habits’ activities), 2) the targets 
most often addressed (e.g., increasing strength, improving ability to grasp/release 
objects, increased independence with dressing, etc.), and 3) the active ingredients of 
interventions used to treat adult stroke patients with UE hemiparesis. 
 
• Feasibility and Acceptability Surveys  
After data collection is complete, we will administer electronic surveys via REDCap 
to all OT practitioner and patient participants who had at least one OT session 
recorded to gauge their acceptability and comfort with being video recorded. In 
addition to study-specific questions about logistics, scheduling, and overall approach, 

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we will also incorporate well-established implementation science survey metrics to 
quantify acceptability of this approach (Weiner et al., 2017). Refer to ‘OT 
Practitioner Feasibility Survey’ and ‘Patient Participant Feasibility Survey’ 
documents for the questions we will ask. Of note, consent to complete this survey 
will be provided in the paper consent form at the beginning of the study for both video 
recordings and the survey at the end of their data collection.  
 
Data Management 
Videos will be recorded on SD cards and transferred to a secure electronic repository 
behind The Ohio State University Medical Center firewall for storage. After transfer, all 
videos will be deleted from the SD cards. Scanned informed consent forms and all other 
data (e.g., demographics, clinical characteristics, medical chart data) will be directly 
entered into REDCap. Upon enrollment, OT participants will provide their name and e-
mail address which will be entered into a master key in REDCap with their OT subject 
ID. They will be provided with a secure survey link from REDCap so that they can 
complete a survey with their demographics and clinical characteristics. Patient 
participants will verbally provide their name and date of birth after enrollment to a 
member of our study team, which the study team member will manually enter into 
REDCap at which time their subject ID will be assigned. Their information will be stored 
in a secure, access-controlled electronic master key in REDCap and any data extracted 
from their medical chart will be tied to their subject ID only in REDCap. Videos may be 
used for educational or research purposes and participants will be made aware of this. We 
will blur/cover identifying features if we use videos for educational or research purposes 
to protect confidentiality. In the event that we wish to use video recordings for 
educational/research purposes without blurring the face of the participant or therapist, we 
will obtain additional explicit written permission from the therapist and patient to do so.  
Figure 3. Framework to Guide Analyses of Video Recorded Data  

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Potential Risks  
While this study is incredibly low risk, all studies come with some level of inherent risk. 
The greatest risk in this study will involve a risk to data security. As such, we will take 
extra precautions to ensure data is managed effectively and stored appropriately.  All 
information collected from stroke patients and their medical charts will be coded and 
linked only to them by a secure, access-controlled master key. No personally identifiable 
information will be collected from stroke participant charts, thus there is minimal-to-no 
risk of patient privacy being breached. We will put strict quality controls in place to log 
and upload video data from SD Cards to a secure, firewall-protected server after 
recording and then delete the data from the SD cards immediately after upload. A full 
HIPAA waiver will be requested from Ohio State’s IRB to allow the research team to 
access medical charts via IHIS where data will be extracted and tied to participants by 
subject ID only.  
Protection of Privacy and Confidentiality 
For all potential participants, the informed consent process and data collection interviews 
will take place in private or secluded settings with minimal foot-traffic. As almost all data 
collected will be observational, it will be done within the traditional context and setting 
of participants’ rehabilitation and professional activities. All data collected and stored 
online will use secured, encrypted drives. We do not anticipate collecting any data using 
paper forms, however, should we need to do so these documents will be stored in access-
controlled, locked filing cabinets. 
All participants will be assigned a subject ID which will link them to their data only by 
an access-controlled master key. Data will be stored in REDCap, as will all data obtained 
through any electronic surveys. Recordings will be stored on secured drives. Participants 
whose treatment sessions are observed will be instructed to maintain the confidentiality 
of the other participants’ information. 
Protection from Undue Influence 
We will make every attempt to minimize undue influence or coercion for employees of 
our rehabilitation settings. Several strategies will be used. OT practitioners will be made 
aware that choosing not to participate will not affect performance evaluations (favorably 
or unfavorably), career advancement, or other employment-related decisions. This 
information will be reiterated during the initiation of data collection sessions. All 
informed consents will contain this information and that participation is voluntary. 
Patient participants will be made aware that not participating or ending their participation 
at any time will not result in negative consequences or changes to their care.  
D. Data Analysis 
Video Coding Analysis 
A video coding structure has been developed incorporating principles of the RTSS to guide 
analyses (Figure 3; Wengerd, 2019). Treatment Activities: The RTSS recommends that all 
treatment activities, based on their primary target, be categorized into one of three 

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categories: 1) Organ Functions, 2) Skills and Habits, or 3) Representations. All observed 
treatment activities will be categorized into one of the three RTSS categories, and their 
respective subcategories, or into a fourth category of assessment (not currently existing in 
the RTSS framework). All seconds of the session will be categorized as ‘active time’ (i.e., 
activities in each of the four categories), or ‘inactive time’ (i.e., when the patient does not 
engage in therapeutic activity for greater than 15 seconds consecutively). Treatment 
Targets: Treatment activities will also be coded with a corresponding treatment target, 
using a list of 75 potential targets developed through a review of three ICF Core Sets: 1) 
Rehabilitation Set, 2) Stroke Comprehensive, and 3) Neurological Post-Acute 
Comprehensive (Bickenbach et al., 2012). To help facilitate the categorization of treatment 
activities and targets, therapists will be asked to state the primary purpose for each 
treatment activity during video recording (e.g., “let’s work on stacking cones to increase 
your shoulder strength”), however clinical reasoning and chart reviews will also be 
employed to confirm coding accuracy. Active Ingredients: A coding scheme for measuring 
active ingredients was developed based on previously reported treatment ingredients 
(Cirstea & Levin, 2007; Gillen, 2015; Host et al., 2014; Stein, 2015; Taub & Uswatte, 
2006; Wolf & Nilsen, 2015), discussion with OT practitioners in the field, and clinical 
experience. Active ingredients will be coded according to this schema as duration-based 
(time spent using the ingredient), frequency-based (number of occurrences), or both. 
Activities will be assessed for the following ingredients and coded accordingly: 1) whether 
feedback was provided, and in what way (e.g., knowledge of performance versus 
knowledge of results), 2) types of cues provided (e.g., verbal, tactile, etc.), 3) assistance 
provided by the therapist (e.g., active assisted range of motion) and 4) whether 
grading/shaping occurred, and in what way. All active ingredients will be coded as 
‘present’ or ‘not present’ for each treatment activity. We will also code materials, 
equipment, and/or modalities used for each treatment activity (e.g., material ingredients). 
Once all active ingredients are coded with the INTERACT software, we will use the data 
to systematically describe the activities during treatment sessions using a template 
recommended by the authors of the RTSS (Tessa Hart et al., 2019). The total number of 
videos recorded per participant and per therapist will be tracked. This includes videos 
recorded during each study visit and any additional sessions deemed necessary by the study 
protocol. The average number of videos recorded per participant and therapist will be 
reported in the final study analysis to assess consistency in data collection. The number of 
videos successfully analyzed will be reported, alongside any discrepancies or challenges 
encountered during the analysis process (e.g., missing data, technical issues). These metrics 
will be included in the study report to provide transparency in the data collection and 
analysis process. 
Video Coder Training  
Each video analysis will be conducted by trained video raters in several passes to determine 
1) treatment categories and targets, 2) durations, frequencies, and repetitions, and 3) active 
ingredients. A minimum of 20% of all the videos will be assessed for interrater reliability 
(≥90%), and minor adjustments to the coding manual may be made. To ensure fidelity, all 
raters will participate in comprehensive training with a member of our study team and will 

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be provided with instruction manuals developed for this analysis. Consistent with previous 
studies, raters will be required to code a mock treatment session using the established 
framework and reach 90% agreement with the coinvestigator prior to independently coding 
video data (Lang et al., 2009; Winstein et al., 2003). Videos will be coded and analyzed 
largely by occupational therapy doctorate (OTD) students in their second or third year of 
the program, which we previously demonstrated worked well with high interrater reliability 
(97%) for RTSS treatment groups (Wengerd, 2019).  
 
Statistical Analysis 
Data coded using INTERACT will be entered into REDCap and subsequently analyzed 
using SPSS Statistics. Descriptive statistics will be used to describe the study sample, and 
all observed treatment categories, treatment sub-categories, treatment targets, and active 
and material ingredients. Shapiro-Wilk tests will be conducted to assess for normality. 
Survey results will be reported using descriptive statistics and will be used to inform our 
video-based observation toolkit development in order to maximize implementation and 
acceptability of this approach.  
 
Development of a Video Observation Toolkit 
The overarching purpose of this Aim 2 is to manualize an approach for video observation 
to characterize rehabilitation interventions comprehensively using the RTSS framework. 
This manual will cover the following areas to advance the fields of rehabilitation and 
implementation science: 1) a comprehensive overview of the pros and cons of video 
observation compared to traditional implementation science approaches (e.g., chart review, 
surveys), 2) a step-by-step guide on how to create buy-in with community stakeholders to 
conduct this kind of work, and how to setup video observation that is unobtrusive to 
standard care; and 3) a detailed description of how to comprehensively analyzes video 
observations using the RTSS framework in OT practice settings.