Recuperation, recovery, and rehabilitation.

Rehabilitation is associated with many R words: restoration, reablement, recuperation, reactivation, recovery, reintegration, and other variations on the theme. Is this a helpful disaggregation of the rehabilitation process, or does it confuse and obfuscate? This post explores this question. This is essential because many people draw distinctions between these and other terms, such as intermediate care, using their distinctions to select patients who may or may not receive their service. I have already discussed this on this site, concluding, “starting in about 1990, people started using a range of new words to describe services delivering services identical to rehabilitation but limited to specific circumstances. The evolutionary process has formed several new rehabilitation species, adversely affect rehabilitation by confusing commissioners, patients, and people referring to such services. It also limits the flexibility, resilience, and ability of services to become more expert. Words do have consequences. It would be better to use rehabilitation to describe all these different services.” In this post, I will explore some of these terms in more detail, especially recuperation and recovery. I do so from a new perspective, using the General Theory of Rehabilitation because it helps disentangle the many nuanced differences between the concepts.

Introduction

Words matter. They represent concepts and ideas we use when analysing and discussing an issue; we need words to learn or work collaboratively on complex or long-term projects.

Words are also imprecise. Each word refers to some core idea, the Platonic ideal, which is surrounded by a penumbra of closely associated meanings. A dictionary describes the core concept and a thesaurus enumerates aspects of its penumbra. For example, rehabilitating is associated with restoring, reintegrating, readapting, and retraining. The word’s core concept may change with time and vary among people, cultures, and countries using the same language.

Imprecision has consequences. Nuance and subtle, significant differences can be expressed and are qualitatively essential. However, if the word is used as if it had a definite, immutable meaning with precise boundaries, it is being used quantitatively to allow categorisation and counting. Then, many difficulties arise because other people will use a different meaning or, more likely, may not accept that such precision should exist.

This difficulty is only too apparent in rehabilitation. For example, there is no difference between health and social care, except that, in the UK, healthcare is free, whereas social care is means-tested. The Department of Health has a laborious system intended to make the distinction, the Decision Support Tool, but eventually, the difference is a matter of judgment; when your budget is limited, judgment is inevitably biased.

Many aspects of rehabilitation are imprecise, as is the word. Is rehabilitation distinct from convalescence? The term convalescent rehabilitation suggests not. How does slow-stream rehabilitation differ from complex disability management or specialist rehabilitation? I shall start my investigation with recuperation.

Recuperation and rehabilitation.

Recuperation is “recovery from illness or exertion” [OED]. Many words are linked to it in a thesaurus, including ‘convalescence’, ‘bounce back’, ‘rally’ and ‘recovery’. The term is used in military circles where troops may have a rest and recuperation spell after active duty. The exact phrase was used in a qualitative study of patients after liver transplantation: “… the focus on activity rather than rest and recuperation was experienced as counter-intuitive.”

The only definition I have discovered is, “Recuperation, in this study, was taken to mean the regaining of balance and control following any loss, for example the loss of one’s health.” This was in a 1989 thesis by Marion Healey-Ogden. This seems to encompass recovery and adaptation.

There is little difference between recuperation and convalescence, except when used financially, when it means the recovery of money owed. Therefore, for this post, recuperation will be considered synonymous with convalescence, “time spent recovering from an illness or medical treatment; recuperation.” [OED] I have discussed convalescence, recovery, and rehabilitation.

A medical committee used the term “convalescence” to describe rehabilitation in 1926 when they recommended that “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.”

Then, in 1939, Ernst Boas discussed convalescence and chronic illness, advocating active programmes to return people towards good health; he explicitly referred to rehabilitation. For example, he discussed diseases where periods of stability were interspersed with relapses and wrote, “Following an acute exacerbation of the illness the proper sort of convalescent care may lead to complete or partial rehabilitation, and may delay the progress of the underlying disease. Such convalescent care is an important therapeutic and preventive agent.”

Next, in a brilliant short essay written in 1946, Howard Rusk, one of rehabilitation’s pre-eminent pioneers, wrote a paper for the American Philosophical Society entitled Convalescence and Rehabilitation. He reported that the US Army had discovered that “… wasted time could be converted into purposeful activity by a well-integrated rehabilitation programme …” which “… led to the establishment of special convalescent hospitals by the Army Air Forces in 1943.”

A recent publication (2018) uses national health-system data to refer to ‘functional convalescence’ after abdominal surgery because convalescence was still coded in the ICD-10. The ICD-10 guidance states, “In the convalescence phase, the patient recovers from an illness or a demanding treatment. The duration of this phase can vary. It depends on how quickly the problems that existed improve. In the convalescence phase, you may need to look after yourself particularly well.”

The close connection between convalescence and rehabilitation is illustrated by the term “convalescent rehabilitation”. A PubMed search on 3 October 2024 found 49 papers using the term; there were 218 further papers, and 264/267 papers were published from 2004 with the majority published from 2014 onwards.

The descriptions of convalescence given in early publications include:

providing some nursing and medical care related to disease,
encouraging exercise,
facilitating the practice of functional activities typically relating to work or domestic activities and
explicitly including psychological support and adaptation.

It is rehabilitation.

Recuperation focuses its attention on recovery. However, it may also be used instead of convalescence. Convalescence cannot be distinguished from rehabilitation except that, by implication, it applies primarily to people with an acute onset of illness or disability de novo or as a relapse in a previously stable chronic condition.

Recovery: mechanisms.

Recuperation and convalescence both link to recovery, which will now be discussed. I have discussed how patients and families often have radically different interpretations of the word than the professional using it. However, a philosophical analysis of recovery was published in 2021 and was not discussed in my earlier post. It will be considered at the end of this part because it leads to a much better understanding of recovery.

The Oxford English Dictionary defines recovery as “a return to a normal state of health, mind, or strength” when applied to illness. Other descriptions apply to stolen goods and waste resources. The description is unambiguous about the completeness of recovery; it refers to the end state, not the change process towards some endpoint. This is the meaning most patients and other non-professionals will attribute to a word we use differently; most healthcare professionals make statements such as “You will probably make some recovery”, but recovery’s meaning does not allow qualification.

The process of returning to normal will usually include the following mechanisms.

The first is the repair or regrowth of damaged tissues. Damaged skin reforms intact skin, broken bones remodel and usually approach a typical structure, and lost liver may regrow. When complete structure restoration does not occur, residual, generally detectable structural change will remain. However, structural change only sometimes results in noticeable functional changes in many organs. For example, around 5%-10% of people over 65 years have silent cerebral infarction, detected on a CT scan but never symptomatic, and liver damage may be easily detected on scanning without other losses.

The second is the return of cellular function in tissue that sustained damage sufficient to impair or prevent function without causing tissue death. A good example is the penumbra of some viable, non-functioning brain around a cerebral infarction. The brain’s function improves when cerebral oedema lessens, and the blood supply improves; this mechanism probably accounts for much rapid and significant recovery after a stroke.

The third is an adaptive change in which the organ’s function returns to normal by redistributing function within the organ. If muscle cells are damaged, the remaining cells may hypertrophy and residual healthy kidneys may compensate for damaged kidneys. In this situation, the organ may have less reserve, which may be detectable when the organ is stressed.

Next, the body may adapt. For example, a person with a malfunctioning finger may alter how they use their hands when undertaking a task. This process is often automatic, not requiring the person’s conscious control. People frequently adapt to slowly progressive loss in the early stages with realising they are doing so.

Last, the person may adapt by changing how they achieve a functional goal, for example, using a walking stick (cane) to maintain safety and improve speed when walking outdoors. Common examples include using glasses and hearing aids to correct visual or auditory impairments.

Thus, the process of recovering encompasses many mechanisms occurring at different levels from cells and tissues to a person’s behaviour. The connection between the degree of residual loss at one level, and function at other levels is not absolute. The strength of the association varies in different organs and people.

Recovery: a reframing.

The OED description contains further ambiguity; normality must be achieved in health, mind, or strength. These are three independent concepts. However, I will not explore these. Instead, Yael Friedman’s paper, On recovery: re‐directing the concept by differentiation of its meanings is a helpful review that outlines my approach. She makes two vital points:

recovery must be considered within three distinct spheres: disease, illness, and sickness. She uses malady as an all-encompassing term.
Recovery is described as an outcome, whereas it should be considered a process moving away from the current unfavourable state.

She makes a further point about the prefix used, re-, which applies to recovery and rehabilitation. It strongly implies returning to a previous state. The Oxford English Dictionary [OED] describes it as meaning “once more, afresh, anew,” all words associated with being ‘as before’.

I have explained the terms she uses, including malady, in a post on disease, illness, sickness, and disability. Surprisingly, given her background in psychiatry and philosophy, she does not discuss the biopsychosocial model of illness. I will do so. She reviews papers from various fields highlighting the difficulties associated with recovery and normality within healthcare, which I will not repeat here.

Her first substantive point is that recovery (i.e. a return to normal) in one of her three spheres does not mean that recovery occurs in another sphere and that personal contextual factors have a considerable influence. This leads her to propose three processes associated with the three spheres:

Curing. This concerns disease and is a biomedical perspective.
Healing. This concerns sickness and is, in her view, the person’s perspective.
Habilitation. This concerns illness and is a social perspective.

In Table one, she illustrates the twelve combinations of recovery/no recovery using these three categories. Her paper explores each combination.

Her second substantive point is that recovery is an end goal that someone returns to. One either returns to a prior state or does not. She is strongly influenced by the recovery model used in psychiatry, which emphasises some more crucial concepts.

The key is that the person moves away from their malady towards a state of being well, a model developed in 1939 by a German neurologist and psychiatrist, Kurt Goldstein. He stressed as many people have since, that one can be well even if previously possible capabilities can no longer be achieved. People achieve a ‘new normal’.

She also draws attention to George Canguilhem’s book on normality in health, which I have discussed in three pages on this site discussing the definition of disability, analysis of impairment, and implications of the general theory of rehabilitation. She quotes his book’s sentence, “No cure is a return to biological innocence. To be cured is to be given new norms of life, sometimes superior to the old ones.”

Thirdly, she notes that some people gain something good from their malady once it is controlled or fully overcome. There are many examples, such as gaining more self-confidence, having an opportunity to re-evaluate previous unhealthy lifestyles, meeting new people, acquiring new, more satisfying roles, and so on.

She concludes by suggesting some changes in outlook. Recovery should be considered a process of moving away from a state. Further, the goal is soundness. She implies that this encompasses health, well-being, and functioning or is the opposite of malady, which encompasses illness, sickness, and disease. It also includes feeling whole, at home, and embodied.

Recovery – a synthesis.

Yael Friedman’s crucial insight is that recovery applies to several domains.

The domains she used are easily transposed into the biopsychosocial model of illness: disease is at the organ level, sickness is at the body level, and illness is at the person’s social level. She does not explicitly discuss activities and disability.

Her concept of soundness is best considered as the person regaining a stable equilibrium. The general theory of rehabilitation is centred on this concept. Her text describes the successful adaptation by the person to their new circumstances, and her reference to positive outcomes following a malady is entirely expected within the concept of adaptation.

Therefore, one should not talk about a person’s recovery as if it were an outcome or a state. Instead, one should refer to the adaptation process and say that the person is adapting. Yael Friedman suggests saying the recovery process, but this still suggests an eventual return to normal.

Instead, one should:

Recognise that a disorder (malady, condition) has at least four components, and a person may have changes in one, two, three, or all parts:
- Disease (pathology), affecting organs or organ systems
- Impairment of bodily structure or function, causing symptoms
- Altered function at the level of
  - activities, causing disabilities, and
  - social roles and participation.
- Refer to moving away from this disorder as the adaptation process, not recovery.
- Consider that the end goal is achieving a personal, biopsychosocial equilibrium, not a specific outcome.

Rehabilitation’s role.

I discussed the role of rehabilitation in a recent blog post on resolving complex clinical cases. I will not repeat the discussion and description. I will emphasise some specific points.

Rehabilitation’s role is to facilitate adaptation, which continues until an equilibrium is reached which may be many months or years. Thus, input from an expert rehabilitation service may be needed for months or years. However, as time passes, the input will increasingly focus on analysis and advising (planning) rather than direct actions with the person.

This must be understood because it means that the need for rehabilitation input is not time-limited. Episodes of specific treatments aimed at increasing a function or achieving another specific change will be time-limited. On the other hand, the person must have ongoing access to rehabilitation to resolve new difficulties and give further advice. In other words, the benefits of rehabilitation change from being mainly related to direct assistance to being mostly catalytic, enabling the person to adapt successfully.

Secondly, the end goal of rehabilitation is for the person to establish a stable bipsychosocial equilibrium. No absolute or measurable endpoint can be predetermined as a SMART goal. The person is not aiming for recovery to a previous or specified new state. The end goal of achieving equilibrium applies to all conditions, improving, deteriorating, fluctuating, or stable.

Third, rehabilitation should facilitate adaptation throughout a person’s illness, from its onset. In the early stages after a relatively severe acute illness, the primary role of rehabilitation may be advising on prognosis, preventing avoidable complications, supporting families, and setting expectations. Thus, the early rehabilitation input may be catalytic rather than direct assistance in regaining function for some patients.

This highlights the risks of defining care pathways. Each patient’s need for facilitation by rehabilitation varies in terms of what, when, and intensity.

Conclusion

This analysis of recuperation, recovery, and rehabilitation explored the meanings and implications of each word. It has highlighted how the biopsychosocial model of illness allows a better understanding of change after an illness starts because change occurs in all domains. Moreover, change rarely returns the person to precisely their state before the illness, so recovery is an inappropriate word to use. The analysis also highlights how the general theory of rehabilitation and its emphasis on the person’s adaptation towards a new equilibrium reframes the role of rehabilitation, stressing how the nature of rehabilitation input varies during an illness. It shows that services cannot define pathways or specify measurable high-level outcomes because the goal is equilibrium, not a precise state.