Slow-stream rehabilitation.
What is slow-stream rehabilitation? Dr John Burn is leading a group in writing guidance and standards for nursing homes (care home, skilled nursing facilities) that undertake rehabilitation for some or all residents. This will update guidance from 2013. We recently debated whether slow-stream rehabilitation was an appropriate term to use within the guidance. I argued that it was a phrase with no meaning and, therefore, inappropriate and potentially dangerous. I suggested it risks denying some people rehabilitation, limiting rehabilitation given to others, and wasting resources on people who will not benefit. My argument was based on general principles. In this post, I will review the evidence to see whether my opinion was correct.
Table of Contents
Background
Once upon a time, there was just rehabilitation. Then people started dividing it up. Some divisions described where rehabilitation occurred, for example, in the community, general hospitals, or units only delivering rehabilitation. Other classifications described the intervention, such as prosthetic rehabilitation, cognitive rehabilitation etc. Later, more politically driven divisions arose, such as intermediate care and hospital-at-home services. Usually, the name was given to establish an identity; the name was used to differentiate one service from others as being better.
In 1987 an Australian paper asked, “Slow‐stream rehabilitation: is it effective?” It evaluated a service based in a hospital. Eight years later, in 1995, a second paper described a controlled clinical study of “A slow-stream rehabilitation program for frail elderly patients was developed utilising nursing homes visited by a mobile rehabilitation team based at the hospital from which these patients had been discharged following major illness.”; the data suggested it was effective. Then, from 2005, many more papers were published, primarily from Canada.
The question asked by this post is, what is slow-stream rehabilitation?
What does Google say?
I have searched Google and Google Scholar to discover how the term is used. Asking, “What is slow stream rehabilitation?” gives over 6 million results. The first is “Slow stream rehabilitation refers to a model of service delivery provided to individuals whose recovery is considered to be slow or prolonged, and who are often regarded as being inappropriate for traditional, intensive rehabilitation, in particular those with severe to very severe brain injuries.” written by the Sussex Trauma Network.
The link to this definition is followed by many links to services that provide slow-stream rehabilitation. The services cover many different conditions, occur in many different settings, and imply many different types of service. There is generally some reference to
- being “less intense.”
- being more prolonged with a slower rate of change;
- being effective.
However, these statements do not refer to any comparator nor give any quantification.
Evidence
My search revealed seven papers of interest. I first review six before reviewing the only paper to give a reasonable albeit partial description of the phrase’s meaning.
In 2018, Melody Maximos and her colleagues undertook a scoping review of slow-stream rehabilitation for older adults. They found only one earlier review, which I report next.
Maximos et al. defined slow-stream using the search terms
- slow stream,
- low intensity,
- long duration,
- low tolerance,
- slow to recover.
They excluded studies of people with acquired brain injury.
They extracted data from 18 reports. Apart from two studies from Australia in 1987 and 1995, all pieces were published after 2005. Only three were controlled trials, and one of these was a trial of adding therapy to slow-stream rehabilitation. Fifteen of the 18 were from Canada (12) and Australia (3).
Only some studies gave information about the nature of the service studied, and the authors summarised the available descriptors. The features of note were:
- patients received input between once and five times each week
- session length was 30-60 minutes
- settings included inpatient rehabilitation wards, stroke wards, complex continuing care units, and nursing homes
- length of an episode varied from 30-210 days
- patients with a wide range of conditions were seen, including stroke (even though acquired brain injury was excluded), fractures, deconditioning, and any acute illness.
- Multi-professional teams were involved.
In a briefing paper in 2016, Loretta Piccenna and colleagues reported information generated in a workshop. They also gave data from their scoping review, which included studies of patients with traumatic brain injury. The workshop’s description of slow-stream rehabilitation did not have any features that might separate slow-stream rehabilitation from any other rehabilitation. It described standard rehabilitation (see figure 1 in the paper). The review data found that an episode length ranged from 81 days to five years. Otherwise, the findings were similar to the 2018 review of Maximos et al.
Other papers used the term slow-stream but added no information about slow-stream rehabilitation. I will mention them for completeness’s sake. In an article published in 2022, Melody Maximos and colleagues described the exercises given to 67 people in a community-based slow-stream rehabilitation programme; they gave no further information about the nature of the service. Sarah D’Souza and her colleagues evaluated the effects of a planned environmental change in an acute/slow-stream rehabilitation service, giving no details about the slow-stream rehabilitation service. Carol Parker and her colleagues evaluated the effects of adding functional exercises to a slow-stream rehabilitation programme that was not described.
A detailed description.
Pam Enderby and Jan Stevenson give the best description of slow-stream rehabilitation, in their paper entitled “What is Intermediate Care? Looking at Needs.” They were studying rehabilitation services in the Sheffield (UK) area.
They identified eight local care programmes, stressing that patients moved from one programme to another, and the programmes were not fixed or exclusive. The patient’s needs classified the programmes as being for:
- Prevention or maintenance
- Convalescence
- Slow-stream rehabilitation
- Regular rehabilitation (meaning standard, continuing until no residual need)
- Intensive rehabilitation
- Specific rehabilitation for an individual acute disabling condition (e.g. stroke)
- Medical care and rehabilitation
- Complex, profound disabling condition.
A table gives the aims of each service type, which current local services met the needs, in what settings, to what kind of patients, and who was usually included or excluded. I was pleased to see that convalescence was considered part of rehabilitation, a view I have supported.
This table contains the sole specific description of slow-steam rehabilitation so I will summarise it here.
The aims of slow-stream rehabilitation are to
- provide watchful waiting
- provide assessment/observation
- provide non-intensive rehabilitation/mobilisation
- improve confidence
- actively encourage, extend and facilitate increased speed of recovery
- provide support programme which is being carried out by patients and carers
The services providing it in Sheffield had “generalised and enablement skills” and were classified as community, out-patient, day hospital or home support services. The slow-steam rehabilitation was provided in three settings, nursing homes, intermediate care beds, or at home.
The patients were described clinically as having “stable condition, moderate level of disability, partially dependent, potential for improvement; may have combination of disabling conditions.” Patients included explicitly in the service were “those with mild impairments and disabilities who need specific guidance, treatment and the opportunity to practise new approaches and techniques; those requiring rehabilitation with reduced stamina; those with slowly deteriorating conditions.” Certain patients were excluded, “those more likely to benefit from another programme, and those with stamina and ability to benefit from more active rehabilitation.”
This paper illustrates two significant points. First, patients should always go to the service most able to meet their needs, a message promulgated by Pam Enderby and colleagues in 2016, when they wrote, “The question shifts away from …. to ‘‘what type of rehabilitation is indicated, at what intensity, by whom, where and when?””
Secondly, there needs to be a logically consistent and coherent system of categorising services because the needs of each patient are unique, and they change over time. The difficulties arising from poorly designed classification afflicts current service commissioning in England. Patients must be categorised according to the level of service they need (Levels I, IIa, IIb, and III). However, a patient classified as needing level I may improve once there and then may need to move to another service, even though the first service can easily meet their needs. The enforced move may distress the patient, rupture continuity, and delay recovery and discharge.
Why did slow-stream rehabilitation originate?
I have written about the evolution of rehabilitation. Evolution implies that changes and developments in rehabilitation were a response to new rehabilitation needs or treatments. For example, the emergence of spinal cord injury rehabilitation services was evolutionary. There was an unmet need (people with spinal cord injuries who were dying), and rehabilitation services changed and adapted, slowly discovering what worked and building on it until there was an identifiable, separate service. Prosthetic rehabilitation service following the development of prosthetic technology.
On the other hand, most developments were driven by commercial, political, or other interests.
They were just named and made with no apparent new need or new treatment; the only change was its name and, sometimes, the funding arrangement or management organisation. Examples include intermediate care, enablement services, restoration services etc. I have listed different names for rehabilitation services on another page.
Thus, one must distinguish between the evolution of need, as new conditions or rehabilitation actions become available, and the change in classifications, arbitrary divisions imposed by people in pursuit of some other objective, such as controlling expenditure or furthering their interests.
Slow-stream rehabilitation is a non-evolutionary development, an example of an artificial rehabilitation division without any sound conceptual or evidential basis. It emerged probably from a failure to fund rehabilitation adequately. Providers resorted to a political solution; they ‘invented’ a new idea, and funders bought into the illusion.
This is important because it emphasises that slow-stream rehabilitation is not a specific sub-species of rehabilitation meeting a particular need or exploiting a specific type of intervention. It is a phrase with no meaning other than the meaning wanted by the user or expected by the listener – and, usually, these differ!
Slow-stream rehabilitation – the future.
Suppose you agree that every patient should be seen by a rehabilitation service that can meet their needs. In that case, you should never use the term slow-stream rehabilitation because it does not give any helpful information about the conditions the service can meet or those it cannot meet.
Slow-stream rehabilitation should have no future, and
- no commissioner should look for or commission a slow-stream rehabilitation service;
- no rehabilitation clinician or social worker should ever look for a slow-stream rehabilitation service;
- no rehabilitation service should ever describe itself that way.
Why?
The term slow-stream closes down options,. It may exclude from consideration services that might be better simply because the service has another label. It risks harming patients and wasting resources because their needs are not met as well as they might have been.
The apparent need for slow-stream rehabilitation is often determined without assessing the patient’s needs in detail. The patient labelled as needing slow-stream rehabilitation may be transferred to a rehabilitation described as slow-stream, biut it may be unable to meet the person’s needs. The two parties discussing a patient have quite different understandings of what the patient needs and what the service offers.
The ideal situation is reasonably achievable.
First, we should abandon all artificial service classifications, such as, in the UK, so-called Level 1, Levels 2a and 2b, etc. The later development of many other additional groups illustrates the weakness of the classification. For example the division of level 1 into 1a (high physical dependency), 1b (mixed dependency) and 1c (walking wounded with cognitive/behavioural disabilities) services. At the same time, there are now additional hyperacute rehabilitation services and specialist neuro-palliative care services. These have evolved to meet specific rehabilitation needs and have reasonably informative descriptive labels.
Instead, each rehabilitation service should describe the following:
- What resources it has – professions, numbers, seniority/expertise
- What settings it works in – acute hospital, residential/in-patient, out-patient/day patients, other community settings, home.
- What expertise it has – knowledge, skills
- The usual duration of involvement in one episode – days, weeks, months, indefinite
- Other services it regularly collaborates with
Third, the needs of each patient should be assessed sufficiently to determine the likely best service available for them. This is the responsibility of the rehabilitation team currently responsible for a patient; if no service is involved, whichever service is contacted should undertake a full assessment, determine the patient’s needs, identify which available service the ablest to meet those needs and, if necessary, make a referral. It is never appropriate for s rehabilitation service to state that they are inappropriate without identifying who is appropriate and arranging a referral.
Conclusion
My initial argument, that the label, slow-stream rehabilitation, has no consistent meaning and is not based on any specific features, is supported by the evidence. Slow-stream rehabilitation was most likely a political solution to the failure of funders to pay for rehabilitation services. We must stop categorising patients or services. Instead, we must establish the patient’s needs, review what needs each available service can meet, and then match the patient to the service best able to meet those needs. This requires services to specify their characteristics and what patient needs they can or cannot meet. Put another way; one should always “ask not whether the patient fits this service – ask whether this service best meets the patient’s needs.” (with apologies to J F Kennedy).
