Rehabilitation theory predictions
One feature of a good theory is the formulation of testable predictions arising directly from the theory. This page gives some hypotheses arising from the General Theory of Rehabilitation. Some can be tested, while others can be explored but not tested directly in a randomised controlled fashion. These predictions arise because the theory shifts the perspective. It highlights the critical importance of the ill person adapting to their new situation; it over-rides the treatment-centred biomedical approach, which is still the dominant way of thinking about every aspect of all illnesses; it emphasises the vast range of possible assistance a person may need, extending well beyond health. Thus, it may help transform rehabilitation from a desirable but not vital addition to a person’s healthcare to being the central aspect of healthcare management in all illnesses.
Table of Contents
Introduction - theory
Theories cannot be proven correct. Theories can be better than existing theories, for example, in explaining observed phenomena or being more succinct. Theories also give new insights, suggesting experiments that have not been undertaken and where the outcome can show the theory as incorrect. In a field such as rehabilitation, with many variables and complex interactions between them, it is not easy to suggest simple experiments that will inevitably disprove the theory.
Nonetheless, the General Theory of Rehabilitation provides a new way to consider rehabilitation, and it suggests that changing the focus of rehabilitation interventions and services may lead to better outcomes; it also means that some current interventions may give limited benefit. Three key features of the theory lead to predictions that should improve rehabilitation’s efficiency and efficacy. They may be challenging to test in randomised trials.
The theory suggests that rehabilitation input may catalyse change by improving everyone’s understanding of a patient’s situation, setting appropriate and achievable goals, and developing a practical plan. This can be considered catalytic because the specialist service is unnecessary once the initial formulation and planning are complete. There is no dose-response relationship.
Second, the central role of long-term motivational goals in the General Theory highlights the crucial requirement to make these appropriate to the person’s changed abilities. When people fall ill, they will have existing goals, often not explicit. Their earlier goals may no longer be achievable. In other instances, the person may revise their goals to an unnecessarily low level. The importance of goal adjustment is already recognised, but research into how to undertake it and whether it improves outcomes is limited.
Third, the General Theory emphasises the vital role of patient engagement. The need to be person-centred has been part of rehabilitation’s ethos for decades. The evidence that we are genuinely person-centred is limited, and services are not person-centred, with rules about who may be seen and how long that bear no relationship to the patient’s needs. A radical redesign of services to be person-centred could be undertaken and evaluated; the General Theory would suggest much better outcomes.
Prediction one: the benefit of an initial expert input.
One of the recurrent challenges to rehabilitation has been a focus on establishing a person’s rehabilitation potential. The logic is that there are items that predict who will benefit from rehabilitation so that a simple (low-resource) assessment can be used to select who should be seen by a specialist rehabilitation service. I have published an article and a page explaining the many flaws of this approach on this site. In summary:
- Rehabilitation is not a treatment but a process that includes much more than treatment interventions.
- Until an expert rehabilitation assessment is completed, one cannot judge what might help and how much.
- Items predicting benefit have not been identified for any rehabilitation treatment, and if ever identified for a single intervention, the sensitivity and specificity would likely be too low to warrant their use.
The prediction made is that people with a disability causing problems who have not recently (say within a year) been seen by an expert rehabilitation service will benefit from an assessment as compared with those who have not been seen. Though some people may gain a rapid benefit, a more significant benefit would likely be evident within 12-24 months because many expected changes will emerge later.
A comprehensive geriatric assessment is similar to a complete rehabilitation assessment, except it has a greater emphasis on medical problems and is usually based on an inpatient unit. The research suggests benefits from inpatient assessment, but the evidence does not support using a visiting team; the value in primary care still needs to be established.
Does a complete expert rehabilitation assessment, including a documented formulation and a rehabilitation plan with long-term person-centred goals, benefit patients? This could be studied for inpatients, day patients, outpatients, and people seen in their homes; each setting has potential advantages or disadvantages. The control condition could be an assessment by a less expert service with no plan or simply ‘usual care’, excluding using the specialist team.
Prediction two: goal adjustment.
Lesley Scobbie and colleagues published an initial scoping review on adjusting previously held goals when a person falls ill. They concluded that “effective interventions to support goal adjustment, disengagement and reengagement are lacking.” In a questionnaire study, Roos Arenda and colleagues found evidence suggesting goal adjustment was associated with better outcomes in people with polyarthritis.
Goal adjustment helps adaptation by changing the gap between the present and the aimed-for situation. A closely related phenomenon is response shift, where the person adjusts their quality of life rating. Hence, they report a quality of life similar to their previous measure when more able, even though they would previously have rated it as less good. The exact nature of this phenomenon is subject to considerable philosophical discussion.
However, goal adjustment or altering the personal value attributed to the level of achievement in a goal domain is crucial to the General Theory of Rehabilitation. As expected, the evidence from observational cohort studies suggests it may be associated with a better outcome. However, few studies investigate when and how a rehabilitation service can or should assist, and no evaluative studies reassure us that the benefit outweighs the harm; there must be risks associated with adjusting someone’s goals.
The prediction is that helping someone adapt their goals, including readjusting their desired standards, will be associated with better subjective well-being.
The question is whether an intervention designed to facilitate a person in adjusting their goal and expectations leads to a better outcome. Ideally, some further investigation into when to do this and how to do it should be undertaken before any large trials. Moreover, this process could cause harm, particularly if someone is advised to reduce their aspiration when they can and do achieve it.
Prediction three: self-management
There is no agreed understanding of self-management, which complicates discussion and research. Simon Fletcher and colleagues examined the stroke research into self-management, concluding, “Our analysis positions self-management as a highly nuanced and complex concept, which can fluctuate in its conceptualisation depending on the structures, routines, and the individual.”
Many randomised trials have evaluated self-management. A systematic review of studies of group-based self-management for people with arthritis and “other chronic conditions” concluded that the benefit was small, and another review of self-management for chronic low-back pain reached a similar conclusion.
Stephanie Lenzen and colleagues undertook a scoping review that illustrates one area of ambiguity that may reduce the apparent effectiveness. For example, are goal-setting and action planning part of self-management and, more broadly, can studies that focus on one aspect be considered self-management studies?
A trial by Victoria Manning and colleagues involved 108 people with rheumatoid arthritis who were given a combination of education, individualised arm training exercises to undertake, and self-management training. The whole programme, called EXTRA (Education, Self-Management, and Upper Extremity Exercise), is comprehensive and is shown in the paper.
The General Theory of Rehabilitation predicts that learning self-management will lead to better adaptation, particularly in people with long-term or progressive disabilities. However, it is crucial to define self-management carefully.
The General Theory of Rehabilitation requires a holistic approach to self-management, requiring all professionals to be trained in teaching and willing to relinquish control over aspects of rehabilitation. The question is whether explicitly incorporating training in self-management of every aspect of a person’s illness leads to a better outcome. Practically, answering this would be challenging.
Prediction four: rehabilitation networks
The General Theory of Rehabilitation illustrates the breadth of help a patient needs. Services meeting these needs come from health, social services, housing departments, education, and employment services. Individual needs often cannot be categorised easily. This leads to the piecemeal, uncoordinated delivery of services, often with gaps, waiting times, and different people taking on the same activities. From the patient’s perspective, this is the greatest failure in rehabilitation; from society’s perspective, this leads to waste and an ineffective and inefficient service.
This is an excellent example of How “wrong pockets” Hurt Health. Stuart Butler from the Brookings Institution, Washington DC, has written extensively about the harmful consequences of current financial systems and incentives. For example, he has suggested that Health Care Organisations Should Support Social Services and that Nursing Homes should be Community Hubs, both excellent ideas. England’s recently introduced Integrated Care Boards can start moving in this direction.
Practically, a single budget for all services contributing to rehabilitation is infeasible; virtually every societal organisation will play a role in someone’s adaptation to their illness. The solution is to set up local Rehabilitation Networks that would, among other things, negotiate the sharing of resources to reward collaboration in rehabilitation while not taking on the whole of each organisation’s budget.
The theory predicts what is apparent to anyone; if everyone involved worked together seamlessly, the patient would achieve a better outcome faster, with less stress, and probably using fewer resources.
Although this is testable in principle, it will be impossible to undertake a purely randomised, controlled trial. Nonetheless, helpful information could be obtained with a well-planned prospective observational study starting before introducing networks with the sharing of resources.
Conclusions
The general theory requires a complete change in the organisation of services, the approach of professionals, and the expectations of patients and families. Testing many parts of the theory is challenging and unsatisfactory because if only one aspect of the changes required is evaluated, there may be no detectable difference. Research into how to assist a person in adapting their goals or how they value them and into incorporating self-management into every part of rehabilitation from the outset would be possible and likely to benefit patients. Starting with this more limited research programme might facilitate the broader introduction of changes.
