Rehabilitation and related concepts

We use words to think. The term we use alters our thinking. Words are slippery and dangerous. Consider rehabilitation, reablement, enablement, restorative care, intermediate care, transitional care. These are all words that encompass indistinguishable healthcare processes with similar goals. Further, it is probable that if you use one, your listener takes a different meaning from it than the one you intended. This consideration is not just an academic exercise. In war, major disasters occur regularly because the meaning is “lost in translation” from person to person. In healthcare, disasters do not arise, but misunderstandings may cause delays or failures in providing appropriate care. I have spent hours in meetings discussing whether a person is receiving rehabilitation (paid for by one budget) or not (paid for usually by a more stressed budget). It might centre on a carer dressing someone or helping them dress and allowing them to learn and practice. As I have pointed out more than once, it is like trying to decide if any professional is still receiving education if they go on a course or attend a lecture. (here) This page explores rehabilitation and its surrounding words.

The evolution of rehabilitation.

Rehabilitation derives from the medieval Latin verb, rehabilitate, which meant “to restore to former privileges”. At that time, to rehabilitate someone was to “restore the person to former privileges or reputation after a period of disfavour”. The outcome of rehabilitation was a return to previous social status. The implication is that the individual had behaved in a socially unacceptable way, not necessarily criminal. In 1850, rehabilitation referred more explicitly to a person’s moral status. for a short time.

After nearly 450 years, it suddenly acquired its modern meaning. In 1940, rehabilitation was first used concerning health, referring to returning wounded young men to a productive state.

it is the secret of the maximum cure possible for the patient. It is the process known as rehabilitation. It is not sufficient that the wound should be healed; the wounded part of the patient must be enabled to function again so that he may once more play his part in society as a worker.‥ I have appointed an adviser on rehabilitation.”

MJ MacDonald. Written reply to Parliament. Hansard. 1940

An explosion in the use of the word followed this parliamentary statement. Within five years, people applied rehabilitation to countries, land, economies, cities, and other things. It also was used about people in many contexts, such as rehabilitation of prisoners and people addicted to alcohol and other drugs.

The word remained focused on working-age men who could return to work for many years. Indeed, a postcard of the Rivermead Rehabilitation Centre from the 1970s showed almost exclusively men aged well under 65 years able to return to work. Rehabilitation’s compass expanded from 1990 to include people of any age and with any condition.

Before 1940, healthcare staff used the term physical medicine to describe what is now called rehabilitation. This fact explains the residual, historically-based use of the adjective physical, which accompanies rehabilitation. In addition, in the early years of rehabilitation, the focus was on restoring physical, motor, and musculoskeletal function – so that someone could work in a physically demanding job. Coupled with this focus on physical outcomes was a focus on physical interventions: exercise, massage, and electrical treatments initially, but moving on to surgery, prosthetics, orthotics, and other assistive technology.

From about 1990 onwards, rehabilitation increasingly recognised the importance of psychological factors as a cause of or a contributing factor to ongoing disability and the powerful effects of psychologically-based interventions and processes, such as setting goals to increase motivation and commitment. At the same time, rehabilitation goals have moved from being very functional to much more social outcomes.

Thus, over the last 80 years, the meaning of rehabilitation has expanded from a restricted, circumscribed phenomenon to an inclusive and broadly-based phenomenon. Interestingly, it has, at the same time, returned to its medieval focus on social status. This figure illustrates the history.

Continuing with an evolutionary metaphor, while rehabilitation has evolved to fill every part of the conceptual niche environment, people have used other words to describe perceived smaller parts of the concept. Some of these words also have a long history, such as convalescence, whereas others are new such as reablement. Indeed, reablement is not in my computer dictionary (OED), but it appears on a government website with a definition (below).

Reablement is a strengths-based, person-centred approach that promotes and maximises independence and wellbeing. It aims to ensure positive change using user-defined goals and is designed to enable people to gain, or regain, their confidence, ability, and necessary skills to live as independently as possible, especially after an illness, deterioration in health or injury.

Social Care Institute for Excellence, 2020. here

Therefore, we are in a position where a good word has evolved to encompass a generic process, but a host of new words have appeared, all covering the same process.

Rehabilitation’s competitors

People have recently used many terms in place of rehabilitation. Various motives drive this competition. Some people object to the involvement of healthcare, especially doctors, and wish to differentiate their service from any healthcare association. Some people still think rehabilitation cannot apply to anyone other than a patient with an acute onset, acquired disability. Some people wish to emphasise one aspect of rehabilitation. I cannot see why someone added a new word in many instances.

The list is long, and I may not include them all. Nonetheless, I will give as many as possible to illustrate the problem.

  • Enablement.
    One definition, from a systematic review, is, “The attributes of the enablement concept included: contribution to the therapeutic relationship; consideration of the person as a whole; facilitation of learning; valorization of the person’s strengths; implication and support to decision making; and broadening of the possibilities.” (here)
  • Restorative.
    One definition, from a study on its use in nursing homes, is, “Restorative care is more broadly defined as a philosophy of care that emphasizes the evaluation of residents’ underlying capabilities with regard to function and helping them to optimize and maintain functional abilities.” (here)
  • Reactivation.
    This has been described, in the context of a protocol to evaluate it, as “The program is developed to prevent and/or reduce hospital related functional loss among at risk elderly by offering an individualized treatment plan that is based on problem-solving principles. It includes interventions that are integrated, multidisciplinary and goal-oriented at physical, social, and psychological domains of functional loss and combines existing treatment methods and routes for reactivating at risk elderly persons into an individual care package” (here)
  • Reablement.
    This was defined above, but a second definition is “Assessment and interventions provided to people in their home (or care home) aiming to help them recover skills and confidence and maximise their independence. For most people interventions last up to 6 weeks. Reablement is delivered by a multidisciplinary team but most commonly by social care practitioners.” (here) but see also here
  • Physiatry.
    Physiatry is difficult to define but encompases both Physical Medicine and Rehabilitation, if the two are considered different. (here)
  • Physical Medicine.
    This is also difficult to define and to separate from rehabilitation medicine. A government definition is “Physical medicine is the prevention and treatment of disease or injury with physical methods, such as exercise and machines.” (here)
  • Homecare.
    This is probably impossible to define because it is entirely dependent on the stated intent of the service. The definition given in one review was that homecare “delivered an intervention designed to reduce dependency in ADL for people who were receiving assistance from a paid care worker, compared with provision of routine care where there was no explicit intention to reduce dependency.” (here) As both services are likely to help improve performance through practice, it seems difficult to define.
  • Intermediate care.
    This subsumes a mixture of services. One definition is “A range of integrated services that: promote faster recovery from illness; prevent unnecessary acute hospital admissions and premature admissions to long-term care; support timely discharge from hospital; and maximise independent living. Intermediate care services are usually delivered for no longer than 6 weeks and often for as little as 1 to 2 weeks. Four service models of intermediate care are available: bed-based intermediate care, crisis response, home-based intermediate care, and reablement.” (here) and see also here.
  • Enhanced recovery programme.
    These were developed for patients undergoing surgery and share many elenents common in rehabilitation. One description states that the “share common elements such as patient education and involvement in preoperative planning processes, preoperative oral carbohydrates, improved anaesthetic and postoperative analgesic techniques to reduce the physical stress of the operation, early oral feeding and mobilisation.” (here)
  • Prehabilitation.
    This is another term for an enhanced recovery programme, and has been described as “multimodal prehabilitation including respiratory, aerobic and/or resistance training programs as well as nutritional and psychological interventions“. (here)
  • Convalescence.
    This word is often used in conjunction with rehabilitation when describing a service offered, and its dictionary description shows the similarity to rehabilitation: “time spent recovering from an illness or medical treatment; recuperation”. [OED]
  • Restorative home care.
    Restorative home care “involves reorienting the focus of the home care team from treating disease and creating dependency to maximizing function and comfort; … functional and repetitive exercises incorporated into activities of daily living; … home care aide training and enhanced supervision; … health professional training; … comprehensive geriatric assessment; … and coordinated care management.” (here) Sounds like a description of rehabilitation!

Are these all rehabilitation? The answer depends upon your interpretation of what the word rehabilitation includes. I have discussed the impossibility of drawing boundaries around any word, especially rehabilitation, and will not repeat the discussion here. (see here)

One way to consider this problem is to expand the evolutionary metaphor. Rehabilitation evolved to fill a niche within the healthcare conceptual framework. As rehabilitation increased its scope, new sub-species of rehabilitation developed, filling niches characterised by the funding organisation (e.g. Social Services) or by the absence of an active rehabilitation service (e.g. covering the transfer from hospital to home). Ideally, all these new names (species) should be recognised as part of the parent speciality (rehabilitation). We should name services with titles that acknowledge that they deliver rehabilitation, identifying their distinct feature (if any) using an appropriate adjective.

I suggest that these words all include structures, processes, and outcomes similar to those of rehabilitation and often indistinguishable from rehabilitation. For example, most include multi-professional input, multiple interventions covering different areas of interest, and patient-centred functional outcomes. They do not focus on disease diagnosis and management. In other words, “If it looks like a duck, quacks like a duck, and flies like a duck, then it must be a duck.”

Several problems arise from using these words to describe the rehabilitation activities undertaken.

Commissioners may be confused and commission two or three services that may see similar patients so that different patients with the same problems will pass through different service pathways. This is inefficient. Each service will be smaller than the potential whole, combined service. This leads to less flexibility and resilience in managing staff changes, increases in demand, and other changes. The teams have less expertise because they have less experience, and individual staff cannot build up specific expertise.

People referring to services may also be confused. They could refer patients to any of the similar services, and often, in this situation, they will refer a patient to two or three services simultaneously. This wastes resources. Further, because usually a service is only funded to see a patient for a limited time, a patient who needs more input will be referred to another similar service. This is inefficient because the second service will undertake a further initial assessment.

It will also lead to confusion in research. Systematic reviews may miss rehabilitation research if the researchers give the intervention another name. A reader of the study may not appreciate that the intervention is rehabilitation, and may consider setting up a new service.

In my view, all services should be within a single service. Nonetheless, if separate services are to continue, they should be identified as

Summary and conclusion

Rehabilitation as a word has existed since 1500. Rehabilitation as a healthcare process has existed since about 1914. Between 1914 and 1940, it developed, termed physical medicine. In 1940, rehabilitation replaced physical medicine but had a limited meaning, applied primarily to acute onset disability in adults aged 16 to 65 years. From about 1960 onwards, its meaning expanded slowly. Now, it refers to all healthcare services that focus on reducing disability and distress and increasing social participation, regardless of the patient’s age or condition and prognosis. However, 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, which has adversely affected 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. If a service remains separate, it should use a specific name, not a term describing the process.

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