In 2007 Peter Halligan and I asked, “Is it time to rehabilitate convalescence?”. No one answered until, in 2022, Gavin Francis also challenged healthcare practice in his book, “Recovery, the lost art of convalescence.” He argues that “from time to time, we all need to learn the art of convalescence”. The medical literature, however, publishes little on convalescence. This post explores the relationships between recovery, rehabilitation, and convalescence. I conclude that all illnesses have a transition period, some shorter than others and that this period coincides with recovery, convalescence, and rehabilitation. I consider a parallel with development from infancy to adulthood, equating the role of rehabilitation to the part of education. I highlight that family, friends and contextual factors are all important additional influences. The period ends when the person has reached homeostasis. The transition can be considered moving from being a patient to being a person.
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Context: a model of illness and health.
Before considering the three topics, I will set a framework for deciding when someone is no longer ill. My hypothesis is like the one used in a paper discussing frailty. Being healthy can be equated to being in homeostasis, meaning that a person can adapt to changes in their situation without moving far from their intended lifestyle and progress. It is not saying they are static – change happens over time in all people as they grow up or age.
Any person with an illness that disturbs normal homeostasis for a significant time (not defined, but usually more than seven days) will enter a critical transition period, moving from their pre-illness stable position to an eventual stable place that may not be the same as before.
Here I am writing about the period of transition starting when the illness starts and ending when homeostasis is re-established. At this point, the individual ceases being a patient and is again a person.
What is convalescence?
The Oxford English Dictionary [OED] says that to convalesce means to “recover one’s health and strength over a period of time after an illness or medical treatment” and that it originated in the late 1400s derived from Latin convalescere, which derives from valere, to be well. In other words, convalescence involves a change in health towards a better state of health with an implication that this takes time. The term does not reveal whether the process requires any input from the person or others; recovery might be natural or facilitated.
There are a few medical definitions of convalescence. For example, E P Boas wrote in 1939, “Convalescence was regarded strictly as “the period between a patient’s acute illness and his return to his previous state of health,””. However, at the end of the same paragraph, he states, “Patients [in convalescent homes] were selected in whom one might expect complete cure and rehabilitation.”.
Another paper by Howard Rusk in 1946 also shows that convalescence and rehabilitation were synonymous at that time. Indeed, he was a former chief of the Convalescent Services Division of the US Army Air Forces. The paper’s title was, Convalescence and Rehabilitation, and its content describes rehabilitation.
Bureaucratic definitions exist. A report on surgical convalescence and convalescent homes in 1926 stated, “a convalescent home should be considered as a place where patients who are recovering from an acute illness may spend the time necessary for them to return to economic efficiency.”
Catherine Cojenta et al. (2018) used the second in a study of hospital beds by women aged 75 years or older in Australia. They used the ICD-10-AM categories to identify convalescent admissions: “Convalescence stays included codes under Z54 (convalescence), Z59 (problems related to housing and economic circumstances), Z60 (problems related to social environment), Z63 (other problems related to primary support group, including family circumstances), Z74 (problems related to care-provider dependency), Z75 (problems related to medical facilities and other healthcare).” However, this begs the question, how did coders interpret convalescence?
Last, Daphne van Vilet et al. (2015) developed a “multidisciplinary consensus on functional convalescence recommendations after abdominal surgery”. The recommendation focused on advice for and education of patients and how they should increase their exercise. They did not discuss how convalescence was distinguished from rehabilitation.
In summary, convalescence has been used to describe the period of recovery after the acute phase of an illness without any consistent comment on the interventions that may occur. It usually includes care, support, and general advice and may give specific advice on exercise and, less commonly, other interventions. I could not find any discussion of a distinction between convalescence and rehabilitation. Indeed it seems likely that between 1940 and about 2010, convalescence was not used. Before 1940, convalescence was equivalent to rehabilitation, and it is now being used again to cover some aspects of rehabilitation.
What is recovery?
Convalescence is usually framed in the context of recovery from an illness. The Oxford English Dictionary says recovery means “a return to a normal state of health, mind, or strength”. Interestingly, its primary meaning relates to health; notably, it refers to a return to normal, which is how most patients and families interpret it.
The term recovery has several associated features. It is a process with no specified duration, but its implied endpoint is normality. The process is considered natural, meaning something that happens without any external agent. This aura of meaning associated with the word recovery leads to difficulties in rehabilitation because healthcare professionals have developed a somewhat different aura around the terms recover and recovery.
When rehabilitation practitioners talk about a person recovering, we usually only mean that there is some change, some improvement. We do not usually mean returning to normal. Indeed, even our interpretation of improvement often stretches the word’s meaning. We will, not infrequently, tell someone there has been improvement, perhaps in a measure of strength, memory function or level of responsiveness, when there is no change in function discernible by the patient or family.
We also rarely mean that the person will return to normal, meaning their state before the illness. Nonetheless, we may well say that someone’s ability to walk or dress will recover. We do not qualify the statement. Unsurprisingly, the patient and family assume a return to previous performance. We may be referring to walking safely without personal support, but slowly, with a noticeable limp and only for five minutes.
Furthermore, we rarely, if ever, consider recovery of social roles and other aspects of social participation. Instead, we focus on impairments because they are easily measured and not too influenced by context, and activities, which are also easily measured but are much more influenced by context. Social participation is, admittedly, much more challenging to measure, not least because there is less agreement on what it is; nonetheless, it is of most importance to a patient.
In summary, recovery refers to the same period as convalescence and is not easily distinguished from convalescence. The difference appears to be that convalescence includes a contextual element, a social recognition of the process that includes providing support.
Although rehabilitation services should be involved from the outset in any illness, there is little initial rehabilitation input, while the priority is making a diagnosis and giving any specific treatment available to control or remove the cause. Consequently, active rehabilitation usually starts when the processes of convalescence and recovery start.
Rehabilitation also eventually stops as a continuing activity; it may become involved again if needed. In practice, the end of rehabilitation is determined by resources and priorities. Still, in principle, it may continue until the person has achieved either the state they were in before the illness (normal) or has achieved an equilibrium where further input will not have any effect.
This is the same time when convalescence and recovery are considered to end. There are, as with rehabilitation, no easy ways to specify when recovery or convalescence finish, but the implication is that they do end.
The significant difference between rehabilitation and recovery and convalescence is that rehabilitation is a process that manages the person actively during the period with the goal of a better outcome.
Equilibrium – the end of the phase.
My review of recovery, rehabilitation and convalescence has shown that all three are concerned with the period of a person’s illness starting once the acute diagnostic and treatment phase is no longer a medical priority. The end of the stage is less easily defined.
My central assumption is that there is a specific phase in any illness that starts with the onset of the episode and ends well before the person’s eventual death. This phase may last from a few days or weeks up to several years, but it is within a context that the person may live for many more years. There is one exception. Some people will have an acute onset illness where a relatively quick death within a few weeks or months is expected. Under these circumstances, the patient may well need ongoing active management from, ideally, a palliative care team.
Otherwise, I assume that all patients will achieve a stable equilibrium where they do not need active input from any healthcare service.
I believe this will apply equally to people with progressively deteriorating conditions whose stable equilibrium encompasses an expectation of slow decline. These people will often have further episodes of disequilibrium requiring a different rehabilitation phase, but they do not need constant healthcare input. On the other hand, if the rate of progression is too fast to allow a stable equilibrium, then palliative care support is appropriate.
Thus, one is looking at an illness (or malady) beginning when one falls ill, with a brief period of medical input focused on diagnosing and treating a disease or, if a disease is not present, establishing that there is no disease to be treated. The person then enters a transitional phase during which they establish either their previous or new state, as described at the beginning.
Therefore, achieving equilibrium or homeostasis is the crucial feature marking the end of the transition from illness, convalescence, recovery and rehabilitation to stability and a new normal for the person concerned.
Humans change and adapt throughout their life. Natural growth and maturation underlie much initial change, with considerable input from family and friends and specific structured input from schools. Among other skills learned is the ability to react and adapt to changes in life.
This transitional phase from birth to late adolescence or early adulthood is educational. Some education is formal, covering facts and skills such as using numbers, reading and writing, and other traditional knowledge. Still, most learning arises from practical and social experience and is taught informally, if at all. For example, a person learns how to travel on public transport, make friends, and act according to social conventions. Some input comes from skilled professionals (teachers), some from family, and most from others.
If an illness disrupts ongoing everyday life, a transitional phase is needed to re-establish equilibrium, and this transitional phase is like growing up. It takes time, though not as long. It involves family, friends, and sometimes skilled rehabilitation professionals. It depends on the person learning from experience and adapting their life to use their strengths.
During the 1920s and 1930s, the transition phase became known as convalescence, and it started to include input from doctors and other professionals; the input was intended to speed the process of change and adaptation and/or lead to a better outcome. After 1940, the term rehabilitation became used for the healthcare input into the transitional phase. However, convalescence has recently been used again to describe this phase after surgery, with the input generally being advice and guidance.
In other words, the need for input from healthcare experts during the transition phase has been recognised for at least 100 years and probably much longer. The transition phase was initially known as convalescences, but from 1940, most of the input has been termed rehabilitation.
This transition phase includes three processes.
One, which we refer to as ‘recovery’, is primarily a physiological process that occurs naturally in response to any damage or loss sustained during the illness. This may involve the regrowth of tissues and will always include adaptation and learning of skills. This occurs naturally but is influenced by social, physical, and personal contexts. This process is equivalent to growing up in childhood.
Next, depending on the nature and severity of the illness, the person may need care and support to preserve safety and well-being. This may be provided by family, or more formally in hospital, in a care home, or by carers visiting the house. This is a component of what is now called convalescence – care that allows recovery to occur by preserving the person’s well-being and may guide improvement informally. This is equivalent to the caring and supportive environment a good home provides for a child,
The third process is an educational input to facilitate the fastest possible change and optimise the outcome at the end of the transition phase. As when growing up, this input comes from family, friends, and expert professionals. Also, as when growing up, this input covers knowledge and skills. Much of it is informal and unstructured, comes from non-professionals and covers mainly the social aspects of a person’s life, which are rarely covered by rehabilitation.
This analysis highlights what is obvious but frequently overlooked; rehabilitation (the expert input from healthcare professionals) is only a small part of the overall input. It encompasses the education, advice, and guidance that is sometimes considered part of convalescence, with many other inputs, such as teaching new skills to enable the person to achieve wanted goals.
This analysis leads to several conclusions:
- All illnesses have a phase of transition from being ill to being back in a predictable, stable state, albeit with slow underlying changes expected from ageing and the disorder
- This transition phase:
- includes the phenomena known as recovery, rehabilitation, and convalescence
- is equivalent to the change from infancy to adulthood
- includes natural physiological changes, provision of support, advice, and learning
- ends when the person has re-established homeostasis, a stable, predictable state
- represents a move from being a patient to returning to being a person
- Rehabilitation plays a small role in:
- promoting the learning of new skills
- giving expert advice and guidance
- educating the patient, family, and others