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Rehabilitation thinking

Rehabilitation is a way of thinking, not a way of doing.” I have written two editorials extolling this approach, but I have recently realised that I have not explained the specific “way of thinking”. This omission struck me as I was writing some new pages for the site (not yet published) on training in rehabilitation skills. This post considers what problem analysis and resolution characteristics lead to better rehabilitation outcomes. The summary answer is to think globally while acting locally. It is essential to place the patient in their whole context, including their past and future. Understanding that the patient in front of you is a snapshot placed within a large canvas will allow you to find the necessary items you can influence to lead to a better outcome over the following years and decades.

Table of Contents

Prologue

The present life of man upon earth, O King, seems to me in comparison with that time which is unknown to us like the swift flight of a sparrow through the mead-hall where you sit at supper in winter, with your Ealdormen and thanes, while the fire blazes in the midst and the hall is warmed, but the wintry storms of rain or snow are raging abroad. The sparrow, flying in at one door and immediately out at another, whilst he is within, is safe from the wintry tempest, but after a short space of fair weather, he immediately vanishes out of your sight, passing from winter to winter again. So this life of man appears for a little while, but of what is to follow or what went before we know nothing at all.”

St Bede. The Ecclesiastical History of the English People. AD 731

This metaphor has thrilled me since I first read it. Although it concerns man’s life, it applies equally well to the encounter between the rehabilitation team and their patients. Our advantage is that we can discover something about the darkness outside and find where our patient hopes to go on leaving the hall. Returning to messy reality, I will now consider how rehabilitation experts should think about their patients.

Context - early experience

The bulk of early training in any healthcare profession quite rightly concentrates on anatomy and physiology because, without understanding how a body works, one cannot understand how diseases and disorders affect people. This primary education on healthy body function should cover, in addition, psychology and cognition. Next, primary education will cover pathology and the significant diseases seen. This is typically structured around the body’s organs with a second framework of different types of pathology.

Thus, it is common to attend to the patient or person with a malady when learning. Because the disease is usually confined to a structure or system within the body, there is a natural tendency to focus more or less exclusively on the part of the patient. When I was training, it was not uncommon for a junior doctor to say to a medical student, “You should go and see the stroke in bed 25.”! Over the next 10-20 years, language progressed to, “You should see the woman with a myocardial infarction on Ward six.”

Patients are probably still described by their diagnostic label, although I hope most professionals are more respectful most of the time. Nonetheless, we may say, “Oh, Mark Jones – he was the man who had a stroke and experienced a supernumerary arm, wasn’t he.” One would rarely say, “Do you remember Alice Jones, who worked in the corner shop in Splott with three grandsons, whom we admitted with symptoms of a stroke?

In their undergraduate years and first few post-graduate years, almost every healthcare professional will focus on the disease when they see a patient. Correctly, they are concerned with learning about the disease, the symptoms and signs, how they vary, and the immediate functional consequences.  They learn to recognise patterns of symptoms and signs associated with specific conditions and how to make or confirm a diagnosis. They usually approach the patient within a framework of solving a closed problem, where there are only a few answers. There is a correct diagnosis and only a few correct treatments.

In summary, most healthcare professionals concentrate on the patient’s disease in the first eight to ten years of their professional life. Consequently, they overlook the much broader aspects of a patient’s life. They also work in a biomedical framework giving relative certainty about diagnosis and management. This determines how anyone starting to train more broadly in rehabilitation will think.

Context - rehabilitation

In contrast, as I have stressed throughout this site, rehabilitation works within a holistic framework, the biopsychosocial model of illness, which is characterised by complexity:

  • Multiple interactions between variables
  • Inter-relationships that are usually non-linear, mutually interdependent, and often two-way

This leads to uncertainty and complexity, a great contrast to the early expectations acquired during education and initial clinical training. It requires a different way of thinking.

In addition, rehabilitation depends vitally on good teamwork. While few people work in isolation in healthcare, the general approach is that a person takes full responsibility for specific processes or decisions. For example, a physiotherapist will decide that a person’s spasticity and contracture warrant serial casting using plaster casts and carry it out. Similarly, a doctor might choose to start an anti-convulsant drug for pain or a nurse to remove a urethral catheter and start toilet training. In each case, the person considers themselves the expert in the matter and, more importantly, will usually act without further consultation.

I am not questioning that individual team members undoubtedly have areas of expertise such that they are rightly responsible for the decision that the action might help. However, in the context of rehabilitation, they must also consider the consequences of every action and how it might affect other team activities. The patient with a plaster cast may use it as a weapon against a nurse trying to help them dress; the anti-convulsant drug might cause confusion or increased problems with swallowing, and the removed catheter might disrupt counselling sessions when the person needs to pass urine.

The team should not make the clinical decision of a team member in deciding what would help if undertaken. However, they should influence whether it is the right decision and, if so, when and how the decision is enacted.

At the same time, a team member may be asked to support an intervention undertaken by a different profession, such as how to communicate with a patient, how to transfer them, or how to respond to certain behaviours. This sharing and blurring of professional boundaries will often extend to undertaking broader assessments, such as a speech and language therapist who is seeing a patient being asked to tell the physiotherapist about some aspect of the patient’s gait.

The greatest challenge associated with a rehabilitation approach is accepting the primacy of broader, patient-centred, longer-term, usually social and not functional, goals. Tension frequently occurs in rehabilitation when a professional determines that they have a “professional responsibility” or “duty of care” to insist that a patient does or does not do something. Common examples include patients who eat food of the ‘wrong’ consistency, walk when they ‘should not’, or won’t take drugs when they ‘should’.

Rehabilitation thinking - global

“Always put yourself in the patient’s shoes.” This would be my summary of how we should think. I have discussed being patient-centred in many pages and posts, and this one gives a good overview.

Being patient-centred means much more than being sympathetic and showing empathy. It requires learning about and understanding the patient’s whole situation, including, but only as a part:

  1. ‘The person’s past and present wishes and feelings’;
  2. ‘The beliefs and values that would be likely to influence his decision if he had capacity’;
  3. ‘The other factors that he would be likely to consider if he were able to do so’.

If you do not recognise this, it is central to deciding in a patient’s best interests when they lack capacity, as specified in the Mental Capacity Act 2005. It is also an excellent guide to considering the patient’s overarching goals when setting goals, and Dekker and his colleagues have developed a tool to help.

Being patient-centred does not come naturally. It is a skill one can learn. One excellent way to become patient-centred is to collect clinical information using the holistic biopsychosocial model of illness as a framework; this has been explored in detail on another page. During the Oxford Case Complexity Assessment Measure (OCCAM) development, we found that a full clinical assessment of 25-40 minutes allowed one to collect information on most aspects of the framework and complete the OCCAM.

Most people know the main components of the biopsychosocial framework as set out by the World Health Organisation on page 9 of its book, Towards a Common Language for Functioning, Disability and Health ICF. This model was a significant advance on the WHO’s earlier framework, which was the basis of the WHO International Classification of Impairment, Disability, and Handicaps. (WHO ICIDH).

Nevertheless, this is an incomplete framework. It included the patient’s context but only recognised two aspects: personal and environmental factors. The International Classification of Functioning (ICF) environmental factors cover social and physical (structural) elements. These two items are entirely separate and will influence each other. The complete model recognises this and has distinct social and physical contexts. On the other hand, adding personal context was a considerable advance, clearly moving towards being patient-centred.

Further, the absence of any temporal context is a major defect. Where someone is in their life and their illness has significant implications for understanding a patient’s situation. I accept that it may not be easy to classify the temporal context, which is the primary concern of the WHO. However, the difficulty or even impossibility of classification does not mean that the context should be overlooked.

Time is already fully integrated into rehabilitation in goal setting; all goals are set in the future. Equally, experience (in the past) may help determine what may work or not work for a patient. However, these two aspects represent only a tiny fraction of the importance of time.

A person’s life up to the start of rehabilitation will be a narrative, a story showing who the person is and determining who they think they are. Narratives are part of a person’s being and will be expected to continue forward. This is obvious in some circumstances. For instance, someone who has just started work as a sailor probably intends to work as a sailor or in related jobs for many years.

In practical terms, one should consider the following:

  • Childhood – schooling, illnesses, any events
  • Adolescence – education, work, leaving home, interests
  • Adulthood to the present – work, conditions, relationships, holidays etc

This can be phrased as a medical history initially because most people will enlarge on that naturally if you let them.

The most challenging aspect of time in rehabilitation is considering the person’s life for the years ahead; what sort of life did they expect, what kind of life do they now expect, and what would they hope for? All decisions should be set in the context of a possible future life some years ahead.

Rehabilitation thinking - local

Thinking globally is essential, but it is not sufficient. A rehabilitation expert needs to find ways to help the patient, which are necessarily small local actions; altering house rules or providing enough support to families providing care are both important, but neither will occur in time to help your patient. Two skills increase effectiveness.

The first crucial skill is finding the essential factors where an intervention will make a difference. Teaching someone how to make orange squash or how to feed themselves in 25 minutes, with help, may be possible, but will it alter their life? On the other hand, some minor changes, such as doing a standing transfer with a Rota stand, might make a huge difference.

The second closely associated skill is thinking laterally, thinking “out of the box”. This may require a professional to use unconventional approaches outside standard professional guidance. It may mean not doing what is usually recommended. In other words, each team member needs to realise that the interventions they are skilled in will not always be the best way to solve a problem. It may also require someone to admit that a solution delivered by someone else would be more effective.

As a simple example, some years ago, I attended a meeting about someone with a prolonged disorder of consciousness; the enteral specialist nurse called it to discuss which management of a failing gastrostomy tube would be in a patient’s best interests as one involved in going against usual practice although it was often used. The “global” thought concerned asking was in the person’s best interests to continue feeding. Once the answer was agreed upon, the local idea was to organise palliative, end-of-life care.

Another example from 30 years ago was attending a meeting on an inpatient where each professional identified operational goals. The global thought was, “this person no longer needs to be an inpatient”, which was readily agreed upon. The local action was to plan her rapid transfer to her home.

Conclusion

I have suggested a way of thinking associated with expert rehabilitation. Being truly patient-centred is its central premise. Using the holistic biopsychosocial model of illness described on the website enables the expert to be patient-centred. Having a global perspective is the second key feature, seeing the patient in front of you in the context of both their past and, more importantly, their future life. The expert then needs to identify key ‘local’ factors that can be acted on to optimise the long-term outcome. This approach means that the expert sometimes needs to subsume their professional opinions on the best actions for the patient’s priorities.

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