Assessment in Rehabilitation.

The verb, to assess, and its noun, assessment in rehabilitation, subvert and extend the verb’s original meaning, which was related entirely to a financial process for calculating how much tax a person should pay. To assess developed generally to mean “evaluate or estimate the nature, ability, or quality of” something. [OED] In rehabilitation, clinicians use both the verb and the noun almost interchangeably with ‘to measure’. In addition, the words have taken on meanings similar to ‘to diagnose’ and ‘diagnosis’ in medicine. This page disentangles the various processes encompassed in a rehabilitation assessment and considers the goals of an assessment. It shows that both measurement and assessment, as used in rehabilitation, involve collecting data and that the difference is in the purposes. Measurement quantifies against a standard; assessment discovers underlying causes and consequences.

Background

All healthcare is a problem-solving activity that aims to improve the duration and quality of people’s lives. All problem-solving starts with someone acquiring data to clarify the person’s problems and determine the causes and how the assessor might resolve them. Rehabilitation is no different from all healthcare in that aspect. As I have said elsewhere, rehabilitation differs in two fundamental ways from most other healthcare. Its analytic framework uses the biopsychosocial model of illness (here). It focuses on activities and how the person interacts with their environment, rather than on pathology, what is abnormal within the body.

Consequently, it is no surprise that rehabilitation is interested in different data types. Given its prioritisation of activities, it uses other methods and investigations compared to most biomedical areas of healthcare. It is also no surprise that a different terminology has evolved. In evolutionary terms, rehabilitation became isolated from mainstream healthcare and speciated, at least in its vocabulary. However, as with species, there are still similarities, and one may learn much through comparing and contrasting the processes and vocabularies.

For example, biomedical diagnostic procedures are often overused without good reason, and clinicians can be overwhelmed with too much data. Much of the data is not helpful, and some suggest other problems unrelated to the presenting problem. It leads to overdiagnosis and the development of new conditions with little evidence to support them.

Rehabilitation is not immune to this problem. Teams can become obsessed with collecting standardised data, often with no better reason than ‘our professional standards require us to do this’ or a consensus guideline suggests it. Ironically, the focus on collecting data in great detail about a few small domains of a patient’s situation may result in nothing known about significant and vital areas of the biopsychosocial model. And incidental and irrelevant abnormalities are detected.

In all healthcare, the solution is the same. All data should be collected for a specific purpose, and that purpose should lead to detectable benefits for a patient. If collecting an item of data will not alter any aspect of patient care, it should not be collected.

Therefore the starting point must be, what are the assessment goals in rehabilitation? Why should we bother? There are goals, and we should worry, but only sufficiently to achieve the goals.

Goals of assessment

The purpose, the overall goal, of the assessment is to enable a sufficiently complete formulation to be made, enough to allow the clinician to start safe and effective interventions. The word ‘problem’ refers primarily to limitations on activities or impairments such as pain that directly affect the patient. The term cause relates to anything that underlies the problems. The analysis undertaken when formulating the situation will be based on the holistic, biopsychosocial model.

In this context, the data collection process may achieve the following objectives, to discover:

  • the problems the patient considers himself to have
  • the problems others think the patient has
  • any problems not identified by the patient or others
  • the causes the patient and others think have led to their problems
  • factors associated with and possibly causing or exacerbating the problems
  • factors that could be altered to lead to a reduction in problems
  • factors that suggest a treatment is more (or less) likely to help.

We will consider each goal in turn briefly.

The patient’s perspective.

It is important to start any assessment by asking the patient to tell you, in their own words, what they think their problems are. And it is vital just to let them explain without interruption. They are the touchstone and all other views must be related to the patient’s viewpoint.

The perspective of others.

This is also important for two reasons. First, they can reveal matters that the patient may not be able to because of poor insight, confusion, communication problems etc.

Second, they reveal the impact of the patient’s difficulties on them, and this may give invaluable insight into their motivations and attitudes when considering rehabilitation goals. They may have very different priorities.

Team perspectives.

When there are no friends or relatives, team members may identify problems not admitted by a patient or forgotten by the patient. I will recall first realising a patient suffered incontinence when, on a home visit, I sat on a wet patch in an armchair!

It is, however, important not to assume that any problems identified by a professional should be managed. The patient may be aware but not concerned, or it might be something long-standing that the patient considers normal or not worth bothering with.

Aetiology & causation

The observed or reported problems will usually have some underlying causes – and there will usually be several or many factors contributing to and/or causing a problem.

Identifying these factors across the whole biopsychosocial model requires a mixture of looking for what is likely, and being systematic in exploring each domain sufficiently to identify important influences.

Moderating or worsening factors

When there is an unexpected observation, such as a greater degree of limitation on mobility than a weakness would suggest likely, one should investigate why. The same applies to rather greater ability than observed losses would suggest possible.

Curiosity about observations, a wish to understand and explain is a vital characteristic of a good rehabilitationist. Not everything can be explained, but looking for explanations can disclose unsuspect information.

Treatable factors

One obvious goal of the assessment is to identify what can be done to help. Some will be obvious -once you have thought of it – but it is easy to miss the obvious.

In 1986 I visited the Astley Ainslie hospital. They reported an intervention that the regional neurosciences centre had overlooked for eight weeks. For two months they had tried to teach a man with ataxia after a traumatic brain injury to walk, and he had become increasingly angry which they said was his brain injury. Giving him a wheelchair in Edinburgh transformed him into a friendly happy man.

Prognostic factors

There are few if any factors known that predict who will benefit more than (or less than) others from an intervention. Most prognostic factors apply to a population and natural recovery, not the ability to benefit.

One exception is finger extension in the affected arm after stroke. The lack of extension at three weeks makes it unlikely a person will benefit from active intervention to improve function. Like all prognoses, there are exceptions but they are rare.

Assessing someone – introduction.

The fundamental logic of the rehabilitation assessment is the same as used when making a medical diagnosis of a disease. The practical application of the process is different from the medical approach because its goals differ and uses another framework or model. The medical diagnostic process establishes the presence of pathology within the body. It appropriately uses the biomedical framework. In the rehabilitation diagnostic process, the assessment’ is interested in understanding the person’s situation, including but not limited to pathology. It takes a holistic approach, being concerned with the person, not their disease, and does so within the biopsychosocial framework.

Taking a holistic view has consequences. One is not interested in discovering a single cause. One is interested in understanding as much as possible about the patient’s problems. Most patients have several problems, and most problems have several factors causing or influencing them. The information needed is much more extensive than simply diagnosing and managing the disease. In addition, the inter-relationships between the many elements are rarely linear, and they often influence each other. The term used for a set of inter-relationships that are multiple, non-linear, and often alter each other is complex. (click for explanation).

Thus, when approaching a patient presenting for rehabilitation, one is considering a complex problem that will not have any single cause, will not have any single answer, and where many factors will be relevant. The clinician needs to have a way of simplifying matters. Fortunately, the biopsychosocial model offers a method. It is a framework, and it allows all factors to be categorised into one of eight categories.

Therefore the assessment can be simplified (?!) into identifying the patient’s problems and collecting information from the eight domains of the biopsychosocial model of illness. The challenge facing any rehabilitation clinician is to collect data from all fields efficiently. The traditional approach, used in many medical spheres, is to ask a series of directed questions covering the essential parts. When I trained as a medical student, we were taught a series of questions for eliciting whether there were problems with the cardiovascular system, the respiratory system, the gastrointestinal system and so on through all organ systems.

This systematic approach to making a medical, disease-based diagnosis ensures that nothing important is missed, and it is appropriate, especially when someone is acutely unwell. Most doctors can cover all relevant systems in a few minutes at most, and there are a limited number of questions. Even so, this ‘review of systems’ is less satisfactory for people with long-term conditions and multiple pathologies because many symptoms may arise from more than one disease.

How to assess in rehabilitation?

In medicine, experienced clinicians rapidly move from listening to the patient to explore hypotheses about the likely disease. Evidence suggests that patients can rarely speak for more than 20-40 seconds before being interrupted, and the doctor (usually) starts asking questions to discover the underlying cause. This method is efficient and effective when the goal is to identify a presumed single underlying cause. The doctor may add a few screening questions to ensure there are no other diseases.

A similar systematic approach is less straightforward in rehabilitation because the number of relevant items is much larger. More practically and importantly, no relatively limited list of questions has been devised to my knowledge. Also, again in practical terms, there is a difference. In a medical context, the question establishes whether or not a symptom is present. The answer is usually short and unambiguous. In a rehabilitation context, one needs qualitative information about how an activity is limited and the consequences, not simply that it is and by how much.

Nevertheless, I suspect that most assessments in rehabilitation follow a systematic, structured course mimicking the medical diagnostic approach, with the professional using rather more structured lists of questions, usually from specific measures to quantify losses. The focus is on collecting data with less thought about why. The approach that works well for doctors (and others) interested in identifying a single disease has been taken on without critical evaluation and without realising that a rehabilitation assessment is utterly different in its goals.

My starting points are:

  • only the patient knows what their problems are, even if they do not appreciate the full extent
  • the patient is more likely to know what factors are relevant that the professional, even if they have not explicitly formulated them in that way

Therefore the best approach is to let the patient tell you everything themselves. This approach is ‘active listening‘, where you let the patient tell you, not in a structured way, but freely following their thoughts. This approach may sound risky, but in my experience, it is often efficient and gives great depth of information. The secret is to keep quiet, avoiding asking any questions as far as possible and allowing the person and, if present, family members to tell you. (Also, see here for a second reference.) You should listen, take extensive notes, and only ask questions to clarify something crucial. All other inquiries should wait. You may structure your notes within the biopsychosocial framework if there is time.

I believe a patient will usually tell you almost everything you need to know, but the information emerges structured around their concerns and beliefs. It does not follow any other logical structure. However, as soon as one tries to structure the conversation, the opportunity to discover the patient’s perspective is lost. Their cooperation and interest are probably lost because they perceive that you are following your interests and are not interested in their concerns.

Once a patient and the family have finished, you should review your notes to identify questions that need answering and ask about any areas of the biopsychosocial model missed.

Measurement?

Assessment and measurement are frequently used as interchangeable words. They are not. Measurement is purely the quantification of a phenomenon. Assessment is a process of collecting data for some purpose.

An assessment may use quantified data. For example, the amount of money earned determines the tax owed. Much of the information collected for a rehabilitation assessment is not quantifiable. For example, information about a patient’s preferred lifestyle or other longer-term goals is descriptive information.

The difficulty has arisen because many people want or feel obliged to collect quantifiable data when undertaking an assessment. The form used is called an assessment rather than a measure used as part of the assessment process.

Measuring should only occur after all critical information has been gathered because it is only then that you will know what needs to be measured. From the patient’s perspective, they will be more likely to collaborate once they understand the reason. In reality, you will need few, if any, measurements to progress clinically. They may be required later to evaluate change, and bureaucracy or clinical audits may require measurement.

Structuring the assessment

Listening actively provides a mass of vital information that the listener will know. The challenge is to record the information in a manner that allows others to use it and find what they want quickly. With practice and experience, one can structure information as it emerges roughly on paper, using the headings from the different domains of the biopsychosocial model. Structuring your notes will often highlight areas you have overlooked.

Each multiprofessional team will need to discuss and agree on the best way to structure information in their clinical record. I can only put forward some thoughts. For example, the solution must be tailored to the work of the service or team. What is suitable for a high-volume out-patient service may not suit a low-volume inpatient service seeing complex patients or a day hospital service seeing patients over many years.

However, I suggest that any solution must use the biopsychosocial model as an underlying framework, both the terminology and the structure, so that anyone joining the team will immediately understand how the record is organised and what the words mean.

I suggest that the OCCAM (see box below) might form a useful summary on one or two pages. It could also create a valuable measure of case complexity when asking for new resources or when asked to justify existing resources.

The OCCAM

The Oxford Case Complexity Assessment Measure, the OCCAM, is a structured record of items from all parts of the biopsychosocial model of illness with a few added items. It is based on another measure, the INTERMED, which has extensive evidence supporting its use as a case complexity measure. When you have finished listening to a patient, it is likely you will have the information to complete most items, and if you bear it in mind when listening, you will occasionally ask a question to obtain specific additional information.

However, the OCCAM should not be used to structure the clinical history or examination, as that would disrupt the flow and reduce the information given. You can ask specific questions afterwards to clarify points and to fill lacunae. The OCCAM is purely a structured way to record and quantify complexity, and it inevitably ensures consideration of each critical domain of the model.

You may download a free copy of the OCCAM here and a spreadsheet for recording scores and sub-totals and totals on multiple patients here.

Summary, conclusions, other pages

On this page, I have suggested that the rehabilitation assessment process is equivalent to the medical diagnostic process with one big difference. Medical diagnosis aims to identify a single disease within the body causing the patient’s problems, and everything undertaken focuses on that goal. Rehabilitation assessment is the polar opposite. It aims to understand a patient’s circumstances in their entirety so that it can resolve or reduce the problems they present with. Medical diagnosis is solving a closed problem, whereas rehabilitation addresses an open problem with no boundaries.

I have also suggested that while medical diagnosis can use a hypothesis-testing approach, gradually eliminating possible diagnoses, rehabilitation cannot. The goal of the rehabilitation assessment is to achieve a suitable formulation of the patient’s situation – what the problems are and how they arise. The formulation will necessarily be based on a holistic model of illness, the biopsychosocial model of illness, which enforces a patient-centred approach described on a second page here. I suggest that the only efficient and effective way to achieve this is through listening to the patient, so-called active listening.

Last, I suggest that the information collected must be recorded in a structured way so that other team members can easily read it and find what they need to know. Naturally, the structure of the clinical record will need to be based on the biopsychosocial model of illness.

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