Establishing Standard Categories of Rehabilitation Approaches in Long-term Care: A Delphi Consensus Study

ABSTRACT

Objectives: This study aimed to establish standardized categories of rehabilitation approaches in long-term care and evaluate their appropriateness through a Delphi survey with an expert panel.

Methods: We adopted the Delphi method using the RAND/UCLA Appropriateness Method. A panel of 15 multidisciplinary rehabilitation experts comprising physicians, physical therapists, occupational therapists, and speech-language-hearing therapists was established. We developed a questionnaire comprising 10 main categories and 58 subcategories based on the glossary review and cross-sectional survey. Panelists rated the categories on a Likert scale from 1 (extremely inappropriate) to 9 (extremely appropriate). The survey was repeated until all categories reached a consensus on “appropriate” and “agreement.”

Results: All 15 panelists participated in three rounds of the Delphi survey. In the first round, although all categories were deemed “appropriate,” one main category and six subcategories did not achieve “agreement.” In the second round, all categories reached the status of “appropriate” and “agreement.” However, some of the comments needed further consideration. After making minor revisions, all items ultimately reached the status of “appropriate” and “agreement.”

Conclusions: This study achieved consensus on the terminology for standardized categories of rehabilitation approaches in long-term care. Future research should assess their reliability and validity using real-world clinical data.

INTRODUCTION

The global population is rapidly aging, with one in six individuals expected to be over the age of 60 years by 2030. Japan is one of the most aged countries in the world, with over 36 million older adults, accounting for approximately 30% of its population.¹⁾ In addition, the declining birthrate and shrinking workforce require the efficient allocation of human resources.²⁾ Older adults often experience multiple health conditions, including frailty, dementia, and other geriatric syndromes, and may require long-term care because of their deteriorating health status.³⁾ Rehabilitation is crucial not only for improving physical health but also for enhancing the quality of life and promoting social participation, especially in the older population. It plays an important role in extending healthy life expectancy and maintaining independence.^4,5,6,7)

The World Health Organization (WHO) aims to improve rehabilitation and integrate it into each country’s health information system,⁸⁾ thereby enabling comparisons of global health status by coding the content of rehabilitation interventions.^9,10) In Japan, rehabilitation has already been integrated into the medical information system, with large-scale data being collected using the Diagnosis Procedure Combination (DPC) system for medical insurance and the Long-term Care Information System For Evidence (LIFE) for long-term care insurance.¹¹⁾ However, a key limitation of the DPC system is that it lacks detailed information on the specific content of rehabilitation approaches.¹²⁾ Furthermore, because the rehabilitation approach between medical care and long-term care is not linked, longitudinal data measurement is challenging.^13,14) Implementing evidence-based rehabilitation in long-term care requires the establishment of standardized codes for rehabilitation approaches, as well as consensus on clinical practice terminology, so that uniform terms can be used in both medical and long-term care. Accordingly, this study aimed to develop standard categories for rehabilitation approaches in long-term care based on expert consensus.

MATERIALS AND METHODS

Study Design

In this study, we applied a Delphi method based on the RAND/UCLA Appropriateness Method (RAM) manual.¹⁵⁾ The Delphi method is a consensus approach used to develop clinical guidelines and evaluate treatments in cases with limited evidence. The RAM combines scientific evidence with expert opinion to assess the appropriateness of care.^16,17) It generally consists of the development of a questionnaire, the Round 1 survey, and the Round 2 survey, which includes feedback on the results of the responses. The procedure followed in this study is illustrated in Fig. 1

Fig. 1.

Development of the questionnaire and Delphi process. Phase 1 shows the flow of the questionnaire development by the working group. Phase 2 shows the flow of the Delphi survey of the expert panel.

Questionnaire Development

A working group (WG)—comprising the first author and co-authors—developed the questionnaire based on a review of terminology related to the rehabilitation approach in Japan and a cross-sectional survey of rehabilitation prescriptions in long-term care.

Review of Terminology Related to the Rehabilitation Approach in Japan

We reviewed the glossaries^18,19) and keywords²⁰⁾ of the Japanese Association of Rehabilitation Medicine (JARM) and the Japanese Association of Occupational Therapists (JAOT). Given that the Japanese Physical Therapy Association (JPTA) and the Japanese Association of Speech-Language-Hearing (JAS) did not have glossaries or keywords, we reviewed the clinical guidelines and extracted terms for rehabilitation approaches used in clinical questions.²¹⁾ Similarly, the JARM’s core texts were reviewed for a comprehensive understanding of terms used in rehabilitation approaches.^22,23,24) Terms extracted from the literature were classified according to the LIFE support codes (Table 1).

Table 1. Result of the glossary review

LIFE support codes		JARM glossary	JAOT glossary	JAOT keywords	JPTA clinical guideline clinical question	JARM core text	JARM comprehensive skills text	JARM rehabilitation approach text in long-term care
Main category	Subcategory
1 Respiratory function exercise	1 Respiratory function exercise	Breathing exercise/Respiratory physiotherapy/Pulmonary (respiratory) rehabilitation	Holistic pulmonary rehabilitation	None	Respiratory physiotherapy	None	None	None
2 Whole body endurance exercise	2 Whole body endurance exercise	Endurance training	None	None	Endurance training/Treadmill training/Aerobic exercise/Aerobic training	Endurance exercise	Endurance (cardiopulmonary function) exercise	Endurance exercise
3 Range of motion exercise	3 Range of motion exercise	Range of motion exercise (ROM exercise)	Range of motion exercise	Range of motion	Range of motion exercises/Joint mobilization/Stretching exercises/Stretching/ Neuromuscular mobilization/Manipulation	Range of motion exercise	None	Range of motion exercise
4 Muscle strengthening and maintenance exercise	4 Muscle strengthening and maintenance exercise	Muscle strengthening training (exercise)	None	Muscle power	Strengthening exercises/Strength training/Muscle strengthening training/Muscle training/Resistance training	Muscle strengthening exercise	None	Muscle strengthening exercise
5 Muscle tension relaxation exercise	5 Muscle tension relaxation exercise	None	None	None	None	None	None	None
6 Muscle endurance exercise	6 Muscle endurance exercise	None	None	None	Muscle endurance exercise	None	None	None
7 Motor function exercise	7 Motor function exercise	Coordination training/Balance exercise	Frenkel’s exercises	None	Cooperation improvement movement/Balance exercises/Balance training	Coordination training/Fine motor training/Balance training	Coordination and balance training/Coordination training/Fine motor training	Coordination and balance training
8 Pain relief	8 Pain relief	None	None	None	None	None	None	None
9 Articulation function training	9 Articulation function training	Articulation (dysarthria) training	None	None	None	Training the articulatory organs	None	None
10 Hearing function training	10 Hearing function training	None	None	None	None	None	None	None
11 Feeding and swallowing function training	11 Feeding and swallowing function training	Eating and swallowing training/Eating training/Swallowing training	None	Swallowing training	None	Direct swallowing training/Indirect swallowing training	Training for dysphagia/Direct training/Indirect training	None
12 Cognitive function training	12-1 Apraxia training	None	None	None	None	None	None	None
	12-2 Visual-spatial perception function training	None	None	Visual search task	None	None	Visual search training	None
	12-3 Language function training	Speech and language training	None	None	None	Speech training/Voice training	Voice training	Training for aphasia
13 Training in learning and undertaking task	13-1 Training in basic learning	None	None	None	None	None	None	None
	13-2 Training in reading	None	None	None	None	None	None	None
	13-3 Training in writing	None	None	None	None	None	None	None
	13-4 Training in calculation	None	None	None	None	None	None	None
	13-5 Training in problem solving	None	None	None	None	None	None	None
	13-6 Training in decision making	None	None	None	None	None	None	None
	13-7 Training in carrying out daily routine	None	None	None	None	None	None	None
	13-8 Training in handling stress	None	Stress coping	None	None	None	None	None
14 Self-efficacy training	14 Self-efficacy training	None	None	None	None	None	None	None
15 Self-awareness training	15 Self-awareness training	None	None	None	None	None	None	None
16 Communication training	16 Communication training	None	None	None	None	Communication training	None	None
17 Changing and maintaining body position training	17 Changing and maintaining body position training	Sitting exercise/ Standing training	None	None	Standing and sitting practice/Standing practice/Posture improvement exercises	Sitting–standing training	Sitting training	Sitting–standing training
18 Sitting-up and transferring training	18 Sitting-up and transferring training	Stand-up training/Standing exercise/Transfer exercise	None	None	Basic motion practice	Basic motion training/Standing training	Basic motion training	Basic motion training
19 Walking and movement training	19 Walking and movement training	Gait training/Ambulatory exercise	None	None	Walking/Walking exercise/Walking training/Walking practice/Applied walking practice	Standing–walking training	Gait training	Standing–walking training
20 Transportation training	20 Transportation training	None	None	None	None	None	None	None
21 Training in using public transport	21 Training in using public transport	None	None	None	None	None	None	Going out: training in using public transportation
22 A series of bathing activities training	22 A series of bathing activities training	None	None	ADL training	ADL practice	ADL training	None	Bathing training
23 A series of grooming activities training	23 A series of grooming activities training	None	None	ADL training	ADL practice	ADL training	None	Grooming training
24 A series of toileting activities training	24 A series of toileting activities training	Bladder training/Bowel training	None	ADL training	ADL practice	ADL training	None	Toileting training
25 A series of dressing activities training	25 A series of dressing activities training	None	None	ADL training	ADL practice	ADL training	Dressing activity training	Dressing training
26 A series of eating activities training	26 A series of eating activities training	None	None	ADL training	ADL practice	ADL training	Feeding activity training	Feeding activity training
27 Self-management training	27 Self-management training	Self-exercise	None	None	None	None	None	None
28 Shopping training	28 Shopping training	None	None	None	None	IADL training	Shopping training	Shopping training
29 A series of preparing meals activities training	29 A series of preparing meals activities training	None	None	Cooking training	None	IADL training	IADL training	Cooking training
30 Cleaning up after meals training	30 Cleaning up after meals training	None	None	None	None	IADL training	IADL training	Cooking training
31 A series of laundry activities training	31 A series of laundry activities training	None	None	None	None	IADL training	IADL training	Laundry training
32 A series of cleaning and tidying up training	32 A series of cleaning and tidying up training	None	None	None	None	IADL training	IADL training	Cleaning training
33 Other housework training (trash disposal, using household appliances, lifting and carrying)	33 Other housework training (trash disposal, using household appliances, lifting and carrying)	None	None	None	None	None	None	None
34 Household goods maintenance training (clothing, automobiles, home appliances, welfare equipment, etc.)	34 Household goods maintenance training	None	None	None	None	None	None	None
35 Housekeeping training	35-1 Taking care of your home and furniture training	None	None	None	None	None	None	None
	35-2 Taking care of indoor and outdoor plants training	None	None	None	None	None	None	None
36 Animal care training	36 Animal care training	None	None	None	None	None	None	None
37 Interpersonal relationship training	37 Interpersonal relationship training	Social skill training	Social skills training	None	None	None	None	None
38 Leisure activity training	38 Leisure activity training	Diversional occupational therapy	None	Music therapy/Dance therapy/Recreation	None	None	None	Training for leisure activities
39 Work training	39 Work training	Vocational training/Pre-vocational training/Vocational rehabilitation	Pre-vocational training/Vocational rehabilitation/Job assistance/Transition support for employment	Employment support/Pre-vocational training/Vocational rehabilitation	None	Training for school attendance and employment	Support for employment	Employment support
40 Environmental adjustment	40 Environmental adjustment	Environmental improvement/House modification	Environmental considerations/Environmental coordination/Housing repair /Residential environment improvement	House evaluation/Housing modification/Environmental improvement/Residential environment improvement	None	None	Environmental adjustment	Environmental adjustment
41 Information provision	41 Information provision	None	None	None	Patient education	None	None	Providing information to patients and caregivers
42 Guidance of nursing care	42 Guidance of nursing care	Family education	Family support	Family support/Family guidance/Patient education	None	None	None	Providing information to patients and caregivers

LIFE, Long-term Care Information System For Evidence.

Cross-sectional Survey of Rehabilitation Prescriptions in Long-term Care

Alongside certified JARM specialists, we surveyed terminology used in rehabilitation prescriptions in clinical practice across 45 facilities in Japan for June and July 2023. Participating facilities provided text-based responses describing the content of rehabilitation prescriptions in long-term care settings. A total of 34 facilities responded (75.6%). The collected text data were categorized according to LIFE support codes, and the number of responses was recorded (Supplementary Table 1).

Composition of the Questionnaire Items by the WG

We developed the questionnaire items through three web meetings and one face-to-face meeting. The literature review and cross-sectional survey revealed three challenges to coding rehabilitation approaches used in clinical practice. First, approximately half of the terms used in clinical practice were not associated with the LIFE support codes, necessitating the development of unique rehabilitation categories based on clinical practice. Second, the terminology for rehabilitation approaches was highly diverse, with no clear consensus or standardized framework. For instance, 19 different terms were used to describe muscle-strengthening exercises (Table 1). Given the use of diverse terms with similar meanings, such as exercise, training, therapy, and practice, among others, the terminology used required standardization. After discussion within the WG, it was agreed that the terms “therapy,” “exercise,” and “training” should be used distinctively, based on the JARM glossary. Third, the targets and actions of rehabilitation approaches were not clear. In contrast to the detailed classification of “exercise therapy” and “feeding and swallowing training” according to the tools used and various methods, the term for interventions targeting activities and participation encompassed multiple areas [activities of daily living (ADL) training and instrumental ADL (IADL) training]. We organized these terms for rehabilitation approaches into first-level and second-level categories from the International Classification of Functioning, Disability, and Health²⁵⁾ and classified them into main categories and subcategories. Finally, we created a questionnaire containing 10 main categories and 58 subcategories and assigned each term to its respective category (Appendix 1).

Establishing the Expert Panel

We established an expert panel comprising 15 members, including 6 physicians, 3 physical therapists, 3 occupational therapists, and 3 speech-language-hearing therapists. The members were selected from among experts recommended by the JARM, JPTA, JAOT, and JAS. The experts were selected from among medical professionals working in the acute, recovery, and long-term care services, all of whom are highly experienced in long-term care rehabilitation.

Delphi Survey and Data Collection

In December 2024, a panelist meeting was held online using Zoom, and the first round of surveys was conducted. The panelists responded to a questionnaire form created using Google Forms, evaluating the appropriateness of rehabilitation approaches on a 9-point Likert scale from 1 (extremely inappropriate) to 9 (extremely appropriate). If the panelist responded to questions with a score of 1–6 points, they were asked to provide comments on how the code could be improved in the question form (free description).²⁶⁾ The questionnaires for the subsequent rounds were developed based on feedback from the panel. The Delphi process was repeated until a consensus was reached on the terms “appropriate” and “agreement” for all categories.

Statistical Analysis

Statistical analysis was performed using Microsoft Excel for Microsoft 365 (version 16.61). Each panelist’s response was recorded on a scale of 1–9, and a median adequacy rating was calculated for each rehabilitation approach. Median values in the range of 1–3 were rated as “inappropriate,” those in the range of 4–6 were rated as “uncertain,” and those in the range of 7–9 were rated as “appropriate.”¹⁵⁾ We evaluated “agreement” or “disagreement” using their corresponding definitions from the RAND/UCLA manual for different panel sizes.¹⁵⁾ “Disagreement” was defined as five or more panelists rating in either extreme, excluding the median. “Agreement” was defined as four or fewer panelists rating outside the 3-point range containing the median (1–3, 4–6, or 7–9).¹⁵⁾

Ethical Approval

This study was conducted in accordance with the principles of the Declaration of Helsinki. The expert panel members were informed of the study’s purpose and content both in writing and during online meetings, and written informed consent was obtained. Given that no personal information was collected, the Ethics Review Committee for Epidemiological Research at Hiroshima University Hospital determined that formal ethical approval was not required.

RESULTS

The Delphi process was conducted over three rounds, and all 15 members of the expert panel responded to all categories (response rate 100%). In the first Delphi round, although all categories were judged to be “appropriate,” one main category and six subcategories did not reach “agreement.” A questionnaire with revised terms was developed based on the panelists’ comments and feedback (Appendix 2).

In the second Delphi round, all categories were judged to be “appropriate” and reached “agreement.” However, the feedback from panelists who rated certain categories as “inappropriate” could not be disregarded, leading to slight modifications of the terms. The revised terms and the appropriateness survey results for the third round of the rehabilitation approach categories are presented in Table 2.

Table 2. Results of the standard code consensus in the three-round Delphi process for each category and subcategory

Category and subcategories		Median score (/9)				Number outside median tertile (/15)
		1	2	3		1	2	3
01 Exercise therapy		8.5	9	9		2	0	0
	011 Range of motion exercise	9	9	9		1	0	0
	012 Muscle strength exercise	9	9	9		0	0	0
	013 Endurance (aerobic) exercise	7.5	8	8		4	0	0
	014 Balance exercise	8.5	9	9		1	0	0
	015 Upper limb exercise (including coordination exercise and manual dexterity exercise)	9	9	9		2	0	0
	019 Other exercise therapy	9	9	9		2	0	0
02 Basic movements training		8.5	9	9		3	0	0
	021 Rolling over training	9	8	9		1	0	0
	022 Rising from spine training	7.5	8	9		5 a	0	0
	023 Remaining in sitting position training	9	8	9		2	0	0
	024 Stand-up training	9	8	9		2	0	0
	025 Remaining in standing position training	8	8	9		5 a	0	0
	029 Other basic movement training	9	9	9		2	0	0
03 Gait training		8.5	9	9		3	0	0
	031 Gait training (level ground)	9	9	9		2	0	0
	032 Applied gait training (including steps, slopes, and outdoors)	9	9	9		1	1	1
	039 Other gait training	9	9	9		1	0	0
04 ADL training		9	9	9		0	0	0
	041 Feeding activity training	9	8	8		3	2	0
	042 Transfer training	9	9	8		1	1	0
	043 Grooming training	9	9	9		0	0	0
	044 Toileting training	9	9	9		1	0	0
	045 Bathing training	9	9	8		0	0	0
	046 Stair climbing training	8	9	8		2	2	0
	047 Dressing training	9	9	9		0	1	0
	049 Other ADL training	9	9	9		1	0	0
05 IADL training		9	9	9		1	0	0
	051 Cooking training (including preparation and clean-up)	9	9	9		1	1	0
	052 Laundry training	8	8	8		1	0	0
	053 Cleaning training	8	8	8		1	0	0
	054 Shopping training	9	9	9		1	0	0
	055 Outing training	8.5	8	8		2	1	0
	056 Training for recreation and leisure	7	8	8		6 a	0	1
	057 Training for transportation use	8.5	9	9		1	0	1
	058 Training for employment	8	9	9		3	0	0
	059 Other IADL training	9	9	9		1	0	0
06 Cognitive function training		8.5	9	9		2	0	0
	061 Orientation training	7	8	8		6 a	1	0
	062 Attention training	8.5	8	8		1	0	0
	063 Memory training	7	8	8		4	0	0
	064 Visual-spatial training	8	8	8		1	0	0
	065 Executive function training	8	9	8		2	1	0
	069 Other cognitive function training	9	9	9		2	0	0
07 Speech-language-hearing training		7.5	8	9		6 a	0	0
	071 Training for aphasia	7	8	9		6 a	2	0
	072 Articulation training	9	9	9		0	0	0
	073 Voice training	8	8	9		3	2	1
	074 Auditory training	8	8	8		2	1	0
	079 Other speech-language-hearing training	9	9	8		1	0	0
08 Feeding and swallowing training		9	9	9		0	0	0
	081 Feeding and swallowing training (direct training)	9	9	9		1	0	0
	082 Feeding and swallowing training (indirect training)	9	9	9		1	0	0
09 Physiotherapy		9	9	9		2	0	0
	091 Thermotherapy	9	9	9		0	0	0
	092 Cold therapy	9	9	9		1	0	0
	093 Magnetic stimulation therapy	9	9	9		4	0	0
	094 Electrical stimulation therapy	9	9	9		3	0	0
	095 Vibration stimulation therapy	9	9	9		2	0	0
	099 Other physiotherapy	9	9	9		2	0	0
10 Environmental improvement and support		8	8	9		3	1	0
	101 House assessment and modification	9	9	9		3	0	0
	102 Assessment and selection of welfare equipment and self-help devices	9	8	9		3	1	0
	103 Education for family members and caregivers	9	9	9		1	1	0
	104 Consultation on support services and systems	9	9	9		3	0	0
	109 Other environmental improvement and support	9	8	9		2	0	0

The terms presented in the table reflect those finalized in the last Delphi round.

^a Items on which no agreement was reached.

Main Categories of Rehabilitation Approaches

All 10 main categories were deemed “appropriate” in the first round; however, agreement was not reached on “speech-language-hearing function training.” Based on the comments of the panelists, the term was revised to “speech-language-hearing training.” Moreover, based on the comments of panelists, “support and coordination” was revised to “environmental improvement” and “support.” Overall, the order of the categories was changed.

Exercise Therapy

In the subcategory of exercise therapy, all five categories were deemed “appropriate” and reached “agreement” in the first round. Based on the comments of the panelists, the endurance exercise was modified to make it easier to understand as an endurance (aerobic) exercise.

Basic Movements Training

In the basic movement training, all six subcategories were deemed “appropriate” in the first round; however, no agreement was reached on “changing body position,” “transferring bed and transfer activities training,” and “standing training.” Based on the panelists’ comments, “changing body position” or “transferring bed and transfer activities training” were revised to “rising from spine training,” and “standing training” was revised to “remaining in a standing position training.” To match the terminology of the two revised training terms, “sitting training” was revised to “remaining in a sitting position training,” and “standing-up training” was revised to “stand-up training.”

Gait Training

In the first round of gait training, all three subcategories were considered “appropriate” and reached “agreement,” but based on the panelists’ comments, a step was added to the applied gait training.

ADL Training

In the first round of ADL training, “agreement” and “appropriateness” were reached in all eight subcategories. However, based on the panelists’ comments, we made slight modification of “feeding training” to “feeding activity training.”

IADL Training

In IADL training, all nine subcategories were rated “appropriate,” but no agreement was reached for leisure training. Following discussions within the WG, the term was revised to “training for recreation and leisure” to match the terminology used for training for employment. Similarly, the term “using transportation training” was revised to “training for transportation use.”

Cognitive Function Training

In cognitive function training, there was no “agreement” on orientation function training and training for apraxia among the seven subcategories. The panelists pointed out that adding “functions” to each training was a limited intervention, so the training was modified to orientation training. To ensure consistency in terminology, “memory function training” was modified to “memory training”, and “attention function training” was modified to “attention training.” It was suggested that “training for aphasia” is unlikely to constitute a standalone intervention and should be included under ADL training or IADL training; therefore, the item was deleted.

Speech-language-hearing Training

After language training did not reach an “agreement,” it was revised to “training for aphasia” according to the panelists’ comments.

Feeding and Swallowing Training

Although we reached agreement on all categories, some modifications were made to the direct and indirect swallowing training categories in accordance with the panelists’ feedback.

Environmental Improvement and Support

Although all categories were deemed “appropriate” and reached “agreement,” some panelists noted difficulty in understanding the practical content of support based on the category names alone. Therefore, the terms in the JARM core text¹⁸⁾ were quoted, and the term “housing environment improvement and house modification” was revised to “housing assessment and modification,” “training for adaptation of welfare equipment and self-help devices” was revised to “utilization of welfare equipment and self-help devices,” and “care consultation and guidance” was revised to “consultation on support services and systems.” In the second round, additional suggestions relevant to clinical practice led to further minor revisions in accordance with the panelists’ comments.

DISCUSSION

In this study, we developed a code comprising 10 main categories and 56 subcategories for rehabilitation approaches that can be used in clinical practice. Consensus on the code was reached using the Delphi method.

The results of the literature review and cross-sectional survey showed that the terminology of rehabilitation approaches in Japan lacks standardization, supporting previous findings on the challenges of collaboration between medical and long-term care rehabilitation. In recent years, attempts have been made in Japan to compare the quality of medical care using big data, and the importance of using standardized process indicators has been reported.²⁷⁾ Using the code we have developed as a process indicator, we hope that comparisons can be made between long-term care rehabilitation facilities and that models can be developed for effective combinations of rehabilitation interventions for each disease. In the future, it will be necessary to develop a common glossary and user manual for the rehabilitation code for rehabilitation-related associations.

Selection bias in panelists has been identified as a potential issue with the Delphi survey method. Rehabilitation should be an interdisciplinary approach involving multiple professionals.^28,29,30) In this study, to minimize selection bias, we established a panel of professionals from multiple disciplines, including not only physicians but also physical, occupational, and speech-language-hearing therapists. This study aimed to develop a standard code for rehabilitation approaches that can be used in clinical practice. Accordingly, we asked panelists who answered 1–6 to make positive suggestions for code revisions.²⁶⁾ In the Delphi round, detailed comments on the code were provided by each professional. By repeatedly revising the code based on these comments, we were able to reach a consensus as a panel.

Although terms related to rehabilitation interventions had not been standardized in Japan, internationally, the WHO’s International Classification of Health Intervention (ICHI)³¹⁾ and the Glossary of Rehabilitation Intervention Terminology of Disease Control Priorities (DCP)³²⁾ have been reported. However, because these classifications and terms have not been published in Japanese, it is currently difficult to check consistency with the Japanese version of the code we have developed. In the future, we plan to check consistency with the ICHI and DCP glossaries and consider its integration.

This study has some limitations. First, in this study, we conducted a web-based Delphi survey using Zoom and Google Forms. The RAND/UCLA manual recommends face-to-face meetings, because the non-face-to-face RAM may result in varying levels of participant enthusiasm throughout the process.¹⁵⁾ Recent reports highlight the convenience and cost-effectiveness of web-based RAM, driven by COVID-19 pandemic.³³⁾ Furthermore, we need to verify the quality of web-based RAM. Second, a potential limitation inherent to the Delphi survey method is the risk that feedback may inadvertently drive participants toward consensus. In our Delphi method, all categories reached the respective status assessments of “appropriate” and “agreement” in the second round. Therefore, this risk should be considered when interpreting the results. Third, although the code developed in this study has been agreed upon by experts, it has not been verified using actual measurement data. Therefore, caution is required before directly applying this code in clinical practice.

In the future, we plan to verify the reliability and validity of the standard codes for rehabilitation approaches based on actual measurement data. Furthermore, it is necessary to verify consistency with the ICHI and DCP glossaries and integrate them into a code with international consensus.

ACKNOWLEDGMENTS

This study was supported by the Ministry of Health, Labour, and Welfare of Japan through the Program for Comprehensive Research on Statistical Information (Grant number: JPMH 23GA2001). We thank Editage (www.editage.jp) for English language editing.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

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