There are thirteen condition-specific competencies. The figure below shows them, and they are listed here, with a short paragraph on each and a link to the competency (in due course).
F-0 condition-specific rehab
Traditionally, healthcare services are mainly centred on organ systems such as neurology, cardiology, and gastroenterology. Other systems have emerged, such as palliative care, oncology, and rehabilitation, but even these often revert to sub-specialisation based on disease types, such as neuro-oncology. Rehabilitation is no different. Spinal cord injury rehabilitation emerged in about 1935 as a separate field of endeavour, and there are many sub-specialised services based on disease or other factors. For example, there are cardiac, assistive technology, and chronic pain rehabilitation services. I now strongly advocate that rehabilitation is a specific approach to illness based on facilitating adaptation, applicable across all conditions. Nonetheless, there are differences between conditions, and this section of the syllabus recognises the differences, describing 13 condition-specific competencies.
Table of Contents
Introduction
This last section considers specific practice areas primarily defined by medical condition diagnosis. This follows the traditional approach to classifying health services based on disease categories or age. Although there is much more to rehabilitation than simply knowing about the rehabilitation of patients with a particular disease class, it is still essential to know about the issues associated with specific conditions. The range of conditions outlined is much more than has traditionally and historically been included in rehabilitation medicine training within the UK. However, the scope has steadily increased since 1995 and is now as broad as any other country.
The 13 competencies chosen are mainly based on the organ systems affected. However, not all rehabilitation has evolved in this way, and the range in neurological rehabilitation is so extensive that it has been subdivided into three (acute, chronic, and spinal cord injury). Furthermore, causation is also used in practice, such as trauma, burns, and limb loss.
Consequently, these competencies have significant overlap, one with another; there is considerable overlap with the earlier 27 competencies. The content of each condition-specific competency focuses on knowledge and skills that are (relatively) unique to the condition.
Why have condition-specific competencies?
Rehabilitation emphasises how it differs from medical healthcare, not focusing on diagnosing and treating disease. Highlighting the difference has had two unfortunate consequences. Politicians, policymakers, and managers have interpreted the difference to mean that medical input is entirely unnecessary and have thus been reluctant to train and employ specialised doctors as part of the rehabilitation team; this is especially the case in the UK, less so elsewhere.
The other consequence is that some rehabilitation team members believe that specialist medical input is unnecessary and that they can get the information they need by asking a non-specialist. This belief means they do not seek specialist input, further strengthening policymakers’ approach.
Rehabilitation is based on the holistic biopsychosocial model of illness, and the disease is a vital part of this model. Disease has a considerable influence on all aspects of the rehabilitation process. The disease determines:
- The patient’s prognostic field. Different diseases have different expectations.
- The likely and unlikely impairments. This guides the patient’s assessment.
- Possible complications. The rehabilitation team should be alert to these.
- The likely rehabilitation problems.
I have written a blog post about a doctor’s role in the rehabilitation team.
Thus, having condition-specific competencies is worthwhile. It ensures familiarity with the issues associated with the condition and especially enables all team members to have some insight into and knowledge of their patient’s diseases. Patients will seek information from any team member, and they must receive a consistent set of information and advice.
The 13 condition-specific competencies.
Neurological rehabilitation – acute.
Although musculoskeletal disabilities are more common, neurological problems constitute a considerable proportion of a service’s caseload because many neurological diseases are associated with more marked disabilities. Research into stroke rehabilitation probably exceeds research into any other single condition, and ideas developed with stroke rehabilitation have influenced rehabilitation greatly. Acute neurological rehabilitation covers especially stroke, traumatic brain injury, metabolic, and infective brain injury. The features are relatively sudden onset, an expectation of a period of recovery which is faster in the early days and may continue for weeks or months, and usually affecting previously well people. Neurological rehabilitation now includes hyperacute rehabilitation, with patients being seen within days of the onset of their condition.
Neurological rehabilitation – long-term
This covers three groups of patients. The first group presents with an acute onset but is left with a persisting disability, sometimes with further acute episodes. The second, much larger group is patients with slower-onset and often progressive conditions. Examples include multiple sclerosis, many genetic disorders such as Huntington's disease, conditions such as cerebral palsy starting at birth or in childhood, and a vast number of rare diseases.
The third group is seen in many different conditions but has been accepted within neurology – people with functional neurological disorders, including non-epileptic seizures. Specifying how such patients are categorised is tough because some patients dispute the label and diagnosis.
Trauma rehabilitation.
The interest in rehabilitation after trauma has grown over the last 20-25 years. Oddly, there was little specific attention to trauma for many years despite war trauma being the principal precipitant of rehabilitation’s initial development. The value of trauma rehabilitation has now been recognised in most countries. Interestingly, though the stereotypical patients are assumed to be of working age, and a return to work was seen as a significant benefit (which it is), most people with trauma are older adults or young children. Trauma rehabilitation crosses many boundaries and encompasses most of the condition-specific competencies. It also covers hyperacute rehabilitation.
Musculoskeletal rehabilitation.
The need for rehabilitation for people with severe rheumatic disorders has been transformed over the last 20-30 years as effective treatments for many of the previously disabling disorders, such as rheumatoid arthritis, have emerged. Osteoarthritis remains a significant disabling condition. However, like neurology, this speciality has a substantial proportion of people with so-called functional disorders such as chronic back pain, fibromyalgia, and hypermobility syndrome. Ironically, the initial focus on physical treatments, which led to using the term physical medicine in association with rehabilitation, is no longer as significant; the need for psychological approaches is correspondingly greater.
Spinal cord injury rehabilitation.
This remains a separate competency because it has historically been undertaken in highly specialised units. However, spinal cord injury is a neurological condition, and many patients are managed successfully in neurological rehabilitation services. Moreover, in the acute phase, patients are often seen in trauma rehabilitation services. Still, the expertise in managing more complex cases can only be gained and maintained in specialist services, which can then disseminate the required competencies to other services. It is neither possible nor appropriate for highly specialist services to take on every rehabilitation need for the person’s whole life; everyone needs some competency in spinal cord rehabilitation.
Cardiac rehabilitation.
This subspeciality developed with cardiological services and has been well-researched. When I was a student, people rested for six weeks after myocardial infarction! Now, exercise is prescribed from the outset. The principles – exercise, psychological support, and reducing the risk of cardiovascular disease – are straightforward. Ensuring that all patients receive rehabilitation and appreciate its undoubted benefits remains an essential area of work.
Pulmonary rehabilitation.
Another speciality-specific field of rehabilitation is closely related to cardiac rehabilitation. For me, it is memorable for highlighting the vital importance of tailoring rehabilitation to the person’s need in its definition of pulmonary rehabilitation, which is “… based on a thorough patient assessment followed by patient-tailored therapies …”.
Rehabilitation in the older adult.
Geriatric medicine was one of the driving forces and early advocates of rehabilitation development in the UK, especially but not only stroke rehabilitation. Older people characteristically have several diseases that interact. Geriatricians developed the Comprehensive Geriatric Assessment, another term for a complete rehabilitation assessment. Frailty is another concept that has expanded from older adults into rehabilitation, as discussed in a blog post.
Paediatric rehabilitation.
This speciality at the other end of the age spectrum also took on a rehabilitation role for the many children with disabling congenital and genetic disorders, especially cerebral palsy. While most are rare, the cumulative total of rare disorders translates into a significant number. Competency in paediatric rehabilitation is essential for all rehabilitation experts, if only because children need to transfer to adult services at some point.
Burns and dermatological rehabilitation.
Rehabilitation for people with burns was highlighted when trauma rehabilitation was developed. Burns rehabilitation, like many disease-specific rehabilitation services, developed in isolation for decades and is still not fully integrated into the field. Dermatological rehabilitation is weak despite the enormous social impact of skin disorders on social participation, but services are being developed.
Psychiatric rehabilitation.
This is another field of rehabilitation that has developed independently. It is vast and includes the rehabilitation of children with learning disability; the process is often referred to as enablement because the goal is not to return a person to some pre-existing state. Psychiatric rehabilitation also includes rehabilitation of people with drug or alcohol dependency. Some people consider this outside the scope of rehabilitation; this attitude overlooks the reality that a significant proportion of all rehabilitation patients have a drug dependency, although often not diagnosed. If rehabilitation is to be truly holistic and based on the biopsychosocial model of illness, psychiatric rehabilitation is inevitably a critical competency needed.
Limb loss rehabilitation.
Rehabilitation of people after amputation was a significant component of early rehabilitation services at the end of the First World War; indeed, though not termed rehabilitation, people had adapted to traumatic limb loss for centuries. In the UK, amputee rehabilitation was part of the Artificial Limbs and Appliance Centre’s work. They supplied prostheses and wheelchairs and were run by the Civil Service, not as a healthcare service.
Visual and auditory rehabilitation.
This is another example of the separate evolution of services that focus on adapting to a disorder. This is not usually included in standard rehabilitation, but it should be. Many patients will have impaired hearing or vision, and this may impact their disabilities and rehabilitation. A small but significant proportion of patients will have impairment in one or both modalities as part of their condition. For example, head trauma with a fractured skull base may cause auditory damage, infective meningitis can damage the auditory nerve, and many conditions giving brain damage can lead to visual problems.
Conclusion
This overview of condition-specific competencies vividly illustrated how rehabilitation services have evolved separately for many conditions. Nine of the 13 competencies have, in the UK, condition-specific rehabilitation services that are isolated from other rehabilitation services. The examples of Long-Covid and trauma have made it evident that we cannot go on developing yet more condition-specific rehabilitation services. Instead, everyone involved in rehabilitation services must be competent at assessing and formulating any patient. Seeking help from a specialist in the condition will be necessary in a small proportion of cases, and professional culture, management structures, and commissioning must enable, even encourage, professionals and teams to work in this way.
