What is rehabilitation? An ‘official’ answer.

As an illustration of exactly how little rehabilitation is understood, consider how NHS-England answered the question, “What is rehabilitation?” in their guide on commissioning rehabilitation, which was published in 2016 (see here):

 

“A modern healthcare system must do more than just stop people dying. It needs to equip them to live their lives, fulfil their maximum potential and optimise their contribution to family life, their community and society as a whole. 

Rehabilitation achieves this by focusing on the impact that the health condition, developmental difficulty or disability has on the person’s life, rather than focusing just on their diagnosis.

It involves working in partnership with the person and those important to them so that they can maximise their potential and independence, and have choice and control over their own lives. It is a philosophy of care that helps to ensure people are included in their communities, employment and education rather than being isolated from the mainstream and pushed through a system with ever-dwindling hopes of leading a fulfilling life. “

That was supposed to help commissioners understand what they were buying. The NHS also wrote it for people likely to use rehabilitation services to judge whether they received sufficient rehabilitation as users.

With that answer to the question in mind, consider:

• if you were a commissioner, paying for rehabilitation, would you have any idea what you would expect to pay for or what the service might achieve?
• if you were a service provider and you wanted to set up a rehabilitation service, would you have any idea what you should be providing and what resources (space, equipment, people) you might need?
• if you were a patient, or a patient’s friend or relative, would you have any idea about what you should expect to receive, what benefits you might gain, and how you would judge the quality.?

What causes the difficulty?

We use words to convey meaning. The meaning is a construct, and it carries the essence of some purpose. A bed can be used for everything from a four-poster Middle Ages bed to a folding light-weight camp bed, from a water bed to a hammock. The essence is ‘the place where I sleep’.

Rehabilitation encompasses many meanings, centred on its original restoration concept. The central meaning has changed somewhat over time, but it retains the idea of change for the better. However, the word is used in many contexts, and in each context, its interpretation will have a different emphasis.

Indeed, rehabilitation is used widely outside healthcare. Criminals in prison are supposed to receive rehabilitation. In practice, all the principles applied in healthcare rehabilitation will apply to prisoners. However, others have used the word about land, economies, countries, and many other objects and phenomena.

This section of the website only discusses rehabilitation in the context of healthcare.

 

Can rehabilitation be defined?

Many people, including me, have attempted to define rehabilitation in the past. I have argued elsewhere (here) that it is simply not possible.

First, it is a word centred on an idea, but there are no boundaries around the central idea. A definition attempts to set boundaries criteria that separate some parts of the meaning from other components. For example, is baclofen or botulinum toxin used to reduce spasticity part of rehabilitation? Rehabilitation may try to reduce spasticity, so it must be. Nonetheless, some people will state that drug treatments are not part of rehabilitation.

Consequently, whatever definition is used, some activities that are part of rehabilitation will be excluded, and others that are not will be included.

Second, the nature of the definition will depend upon the reason for defining rehabilitation. Is it to decide who will pay, or if anyone should pay? Is it to determine whether your service will take responsibility for the patient? Is it to limit the actions that the service is willing to undertake?

If a definition is used for one of these reasons, the patient will suffer because a single service will not help them with all their problems.

What is rehabilitation?
Is description the way forward?

Almost all words in a dictionary describe the meaning of a word. They do not define it. One way forward is to investigate how the word is used and extract the central essence(s) of rehabilitation in healthcare. I have done this. (here)

The method was straightforward. I searched for any systematic reviews of rehabilitation interventions. If the authors said they were studying rehabilitation, then I accepted that. I imposed no criteria because I wanted to see what was included. Of the reviews identified, I selected those that had reasonable evidence of benefit in some domain. I did not use the nature of the benefit as a selection criterion. In addition, to cover some areas of practice where there were no systematic reviews, I identified extensive rehabilitation studies with positive findings.

One set of findings was that rehabilitation is effective:

• when it is delivered in any setting. It is not necessary for the patient to go to an inpatient of outpatient unit specifically.
• for patients with almost any disease. Obviously some diseases are rare, and only common diseases have been studied extensively, but diseases of all organ systems benefit.
• at any stage of a patient’s illness. Benefit is not restricted to the acute phase (as many people assume), and it may well be beneficial until the terminal, end-of-life phase.
• in any and every phase of the condition. It can benefit patients whose disorder is acute onset, or slowly progressive, or fluctuant, or static and stable.
• whatever the type or severity of impairment. There are no levels of severity, or types of impairment that cannot benefit. Specifically the presence of cognitive loss does not preclude successful rehabilitation.
• at any age. There is relative sparse evidence for children, but rehabilitation is effective in people aged over 65 years. (Up until about 1985-90, 65 years of age was considered the oldest person who should have rehabilitation.)

Therefore, rehabilitation can benefit any patient, regardless of their age, condition, phase of illness, and setting.

In terms of positive characteristics, the main findings were that rehabilitation depended upon:

• multi-disciplinary teamwork. This was almost universal. The features of teamwork are discussed later in this section.
• use of the biopsychosocial model of illness. This was almost universally stated or implied.
• use of team meetings for goal setting and planning and coordinating actions.
• expertise in the condition being seen. The condition may have been a disease or set of diseases (e.g. neurological conditions), but also could be defined by impairments (e.g. amputation, cognitive loss and challenging behaviour), or activity limited (e.g. communication aid services and wheelchair services).

Only a few studies explicitly mention the process (or I missed the mention or the studies). Nonetheless, expressly or implicitly, the following features of the process were present in successful rehabilitation:

• structured protocols determining how patients were assessed and how common problems were managed (this is closely allied to teamwork)
• active involvement of the family. Mentioned less often, but reasonably strongly supported.
• regular education for team members

The specific patient-centred interventions (treatments) recorded fell into four main groups that were present in most studies:

• exercise, referring to physical exertion to increase cardio-respiratory work. This was very commonly associated with benefit, usually across many domains.
• practice of activities, which sometimes necessarily involved exercise.
• psychosocial interventions. These were rarely well described but encompass treatment for disturbed emotions, and actions to increase socialisation.
• education, usually of the patient and the family. This was closely related to self-management as a skill to be taught.

However, the most critical aspect of rehabilitation treatment is that clinicians must tailor interventions to the needs and wishes of the patient.

This tailoring took two forms:

• Tailoring the four groups of interventions listed above to the needs and circumstances of the individual patient.
  • It was not sufficient to say “You have condition X and therefore you should do this specific exercise this amount.” It should say, “In the light of your preferred life-style, and your attitudes, and in the light of the resources available to you, and in the light of these clinical features, then I recommend ….”
• Tailoring an additional set of interventions outside the group listed above.

A detailed description of rehabilitation

The empirical description above is a start, but it lacks a formal structure. The remainder of this part of the website will elaborate on this initial description, using the following framework.

What is rehabilitation? Its historical and social context

History explains everything – our successes, our failures, and why we have the difficulties we do. History will also explain how the word has acquired the meaning it has.

Rehabilitation occurs in a social context, and this is particularly relevant. First, the social context determines, ultimately, how much attention and resource is devoted to rehabilitation. Second, rehabilitation is a minor part of healthcare, and the critical other social context is healthcare services and structures, which also determines the attention and resource given to rehabilitation.

What is rehabilitation ? The structures.

The traditional understanding of structures is the buildings and equipment needed for a process. Rehabilitation does have to happen somewhere, but, as shown in the empirical investigation above, rehabilitation can occur more or less anywhere. A building is necessary, but it does not need any specific features, nor is much specific equipment required. Certain interventions will need special equipment, and heavily dependent patients will need typical buildings and equipment, but their rehabilitation does not.

The more critical structures are conceptual frameworks that enable successful rehabilitation. Rehabilitation occurs within a healthcare context, but it differs from most healthcare in many ways. As demonstrated elsewhere, most healthcare is based on a biomedical model of illness, which focuses on disease. In contrast, rehabilitation is based on the biopsychosocial model of illness, which enforces a patient-centred approach.

Thus, the essential structure for rehabilitation to succeed is the biopsychosocial model of illness, and a few pages are devoted to describing this and how it guides rehabilitation.

One consequence arising from the biopsychosocial model of illness is the need for a multi-professional team to undertake the process. You should note I have said multi-professional, not the more usual descriptor, multi-disciplinary. A multi-professional team is more accurate. A multi-disciplinary team may involve many people but only two or three professions. Rehabilitation needs a wide range of expert knowledge and skills and always needs many different professions.

The need for a multi-professional team follows from the breadth of matters that the rehabilitation process will cover. It ranges from disease diagnosis and management at one end, through many different activities such as walking, working, and socialising to housing and helping develop social networks.

What is rehabilitation? The process.

Rehabilitation is analogous to all other healthcare processes – surgery, acute medicine, psychiatry etc. A patient presents with a problem, and rehabilitation clinicians and services try to resolve the issue. Each speciality has its distinguishing feature. For example, surgery sees patients who may need surgical intervention to help them.

I will discuss the distinguishing features of rehabilitation in more detail on other pages. In brief, they are a focus on disability and distress rather than disease and an explicitly long-term and holistic approach to resolving problems.

Otherwise, the process is no different from any other problem-solving process in its phases. Two features differentiate rehabilitation from most but not all other healthcare specialities: the team needs to deliver multiple interacting interventions, not just one or two; and the team’s interventions cover many different illness domains – symptoms control, equipment, housing, employment, etc. – not just one.

What is rehabilitation? The outcome.

All healthcare services will say, not unreasonably, that they wish to improve a patient’s quality of life, and rehabilitation is no different. Rehabilitation differs from most healthcare services in its proximate, immediate goals.

Rehabilitation’s proximate goal is usually to increase independence in functional activities, whereas the comparable goals of most other services are to reduce disease and symptoms. Most patients are more concerned about function than symptoms, except for pain and distress. A change in function is more likely to improve quality of life than a change in disease or impaired physiological function.

Thus, rehabilitation’s goals will generally be more concordant with a patient’s priorities. Of course, a patient will want their disease cured or controlled if possible, but that is a necessary but not sufficient outcome from a patient’s perspective. Curing the disease but not the disability will not satisfy a patient.

Furthermore, rehabilitation often has as its overarching goal optimisation of social participation. In other words, a rehabilitation service will be concerned with establishing or re-establishing a person’s social networks, reducing loneliness, and increasing role participation. These are rarely considered in most other services.

So, what is rehabilitation?

This analysis allows one to understand why there is no simple, universally-applicable answer to the question, “What is rehabilitation?” The answer depends on which aspect of rehabilitation you are interested in:

• the individual interventions given to a specific patient
• the main categories of intervention given across all rehabilitation
• the processes involved in rehabilitation
• the structures needed for rehabilitation to succeed
• the outcomes aimed for
• the people who may benefit
• design and organisation of services
• research

Nevertheless, it is possible to give a description.

 

Rehabilitation is:

• beneficial to any person whose activities are affected by a health condition
• an active problem-solving process
• focused on the patient’s functional activities that are limited.
• undertaken by a multi-professional team with expertise in rehabilitation and the conditions seen by the team
• undertaken within the framework of the biopsychosocial model of illness.
• benefical in all settings