Interventions in rehabilitation
I enjoy do-it-yourself activities because I have to determine how to reach my goal from the first principles. I have to think about what actions are needed. Rehabilitation is the same; the team needs to consider how they will help the patient achieve their goals as nearly as possible. The range of potentially effective interventions within rehabilitation is extensive, and the team need a systematic approach to ensure that they consider all options, not just the obvious ones. This page overviews the different types of action (see graphic). It also introduces the idea that most rehabilitation interventions can be classified into treatment, care, and collecting information. As with all classifications, the reality is that most actions include something from all three categories. However, the conceptual separation is functional when considering service design and resource allocation.
Table of Contents
Rehabilitation achieves nothing unless it intervenes. But what is an intervention? An assessment is an intervention and a well-conducted assessment that actively involves the patient. When the clinician also explains and gives information as the evaluation progresses, it may alter the patient. This conundrum is a variation of Heisenberg’s uncertainty principle; collecting data changes the situation. More prosaically, it illustrates the difficulty in defining and separating processes. When collecting data, one may give the patient data they were unaware of, which may alter their behaviour. The ‘treatment’ or ‘intervention’ provides information, even if this is accidental and unintended.
The problem of identifying how the rehabilitation process benefits patients is not trivial. Ramsay et al. published a description of their rehabilitation intervention in a study investigating an intervention to increase the activity of patients in an intensive care unit. (here) Table four outlines the intervention. It covered six whole pages, four stages, and 12 identified components starting with “Introduction of the patient to GRA, initial assessment, and explanation of rehabilitation strategy”, and the penultimate one was “Telephone patient at least once following discharge.” [GRA = general rehabilitation assistant.] The first component alone included assessment, education, and potential psychological support from the assistant.
Moreover, sometimes it can be an incidental comment:
In my first major research project, I visited patients three weeks after their stroke and again at six months. I saw a 63-year-old man at home after a minor stroke. He had recovered well. I completed my research assessment in about 30 minutes, covering most consequences of stroke. Throughout the interview, the patient and his wife seemed flat without being depressed. I could not ascertain why they were so unresponsive.
When I left, I said, “Well, I’ll come back to see you in six months to see how you are.” They both suddenly looked surprised. “What do you mean?” they asked. “Won’t I be dead then?” A few questions revealed that they thought no one lived more than a few months after a stroke, and a brief educational session made matters right. Both were very active and happy when I returned after six months.
In that case, the ‘intervention’ said I would return six months later. I had no idea that it would benefit him.
Many unplanned, incidental actions probably greatly influence rehabilitation outcomes and contribute a significant proportion of the overall benefit associated with rehabilitation. They include
- empathetic interpersonal relationships between team members and the patient
- a supportive approach that normalises the experiences of and reactions to the disabilities
- listening in a non-judgmental way
- educational chit-chat
- talking with other patients
This page will focus on planned interventions after assessment, expecting they will benefit the patient. It will not discuss the incidental aspects of the process, vital though they are. Furthermore, it does not discuss collecting further data, an activity that may be planned at a rehabilitation meeting and is, as discussed, an intervention.
Rehabilitation, treatment, therapy, and care
Most people think rehabilitation is synonymous with giving and receiving therapy, which implies treatment. [Therapy is “treatment intended to relieve or heal a disorder” (OED) and comes from the Greek therapeutic, to treat medically.] Moreover, most people think that therapy is the only rehabilitation treatment.[Treatment is “medical care given to a patient for an illness or injury.” (OED), and it is the noun derived from to treat, meaning to “give medical care or attention to; try to heal or cure“. (OED)
These words’ descriptions all focus on taking action directly on the patient. Yet many effective rehabilitation actions do not directly affect the patient. For example, arranging a care package, an alteration to a house, financial support, or access to a suitable swimming pool are all rehabilitation actions which may reduce a person’s problems, reduce their disabilities and distress, and improve their quality of life.
The term used on this page, intervention, is more appropriate. It is the noun form of to intervene, which means to “take part in something so as to prevent or alter a result or course of events” (OED), which is a better description of rehabilitation actions, although not perfect.
I will discuss each word used: intervention, treatment, therapy, and care.
A rehabilitation intervention refers to any planned activity undertaken within the rehabilitation process intending to improve the situation. The term encompasses all actions, including treatment, therapy or care but extends beyond those.
However, it must be recognised that starting the rehabilitation process is an intervention, as are all its components. This duality is best overcome by referring to rehabilitation interventions (i.e. interventions that are the active component of rehabilitation, they are a part of the overall intervention involved in the process.)
In other words, a rehabilitation intervention is a generic, non-specific term for all actions started after assessment and formulation and intended to alter the situation.
Treatment is usually an activity undertaken with the patient directly intended to improve upon the expected natural history of a patient’s situation, that improvement being sustained after the course of treatment is ended. The critical features are that:
- it is intended to improve matters; if it does not, it is an unsuccessful treatment.
- it is expected to have an end, with the improvement being maintained after stopping it; continuous ‘treatment’ is care.
This figure illustrates that treatments can be directed at any of the eight domains within the biopsychosocial model of illness. In most cases, the ‘action’ is a complex activity or set of actions. It is often difficult to know the effective ingredients, though attempts at classification are being published; they need studies on their validity and utility.
Therapy is a particularly slippery word because it has two meanings when used in rehabilitation:
- therapy as an activity undertaken by a therapist, and
- being seen by a therapist
It is essential to recognise that:
- therapists engaged in rehabilitation do much more than give therapy to a patient. For example, they will liaise with other therapists, assess and collect data, organise interventions by others, train family members and carers, and do 101 different activities that benefit the patient.
- therapy is an educational activity, and most of the patient’s benefit will only occur if the patient continues to practice without the therapist. The most effective therapist teaches the patient to “do their therapy“.
- Thus, for these reasons, the measurement of contact time is inappropriate for a therapist’s work.
However, therapy should be considered similar to treatment because it is intended to lead to a change sustained after it has stopped. This is not to say that a therapist’s ongoing involvement (including all team members, whatever their title) is inappropriate. Just as someone may benefit from further education, a patient may benefit from an additional episode of ‘therapy’.
Rehabilitation cannot achieve miracles. Many patients cannot achieve complete independence and require ongoing support at a relatively constant level. They need care. Care is an intervention to ensure safety, lack of avoidable harm, and well-being. Care traditionally does not include the external, professional provision of social support and opportunities. When someone needs and receives care throughout their waking hours, they will inevitably develop a social relationship with the care. Still, the intention is to maintain safety rather than to provide social interaction.
Thus, care refers to an action or activity primarily intended to maintain the patient’s physiological stability (life), well-being, and safety (and, sometimes, the safety of others). It covers everything from providing nutrition using a gastrostomy feeding tube and giving ventilatory support through assistance with daily activities, both primary and more complex, to providing a secure environment or a structured, predictable routine.
The separation of care from treatment is conceptual, and a rigid distinction is impossible. A suitable care package will often involve teaching the carers how to encourage and facilitate the patient in practising activities such that the patient may improve. Training and supporting the carers is essential for any expert rehabilitation team. This makes evident the impossibility of drawing a clear line between rehabilitation provided by the health service and ‘social care’ provided by Social Services.
Reflection on treatment v care distinction.
I will explain how the difficulty in making a distinction arises. My premises are that:
- humans learn and adapt throughout life, which applies equally to people with disabling conditions; they still learn and adapt.
- rehabilitation is an activity that teaches the patient how to undertake an activity. More importantly, it teaches how to continue learning the activity through practice.
- most learning, even in a rehabilitation environment, occurs in the absence of specific therapists; for example, when family or carers are around
- patients may need further input from rehabilitation experts from time to time throughout their life, just as all professionals continue their education through Continuing Professional Development
- I highlight the similarity between rehabilitation and education on this page.
- carers, such as family members or paid carers, can facilitate continuing practice and learning.
In other words, the care process itself can also be therapeutic. Supervising someone to ensure they do not fall when transferring is, at first glance, caring. However, encouraging carers to oversee a transfer rather than using a hoist makes it a therapeutic caring activity because the person may no longer need supervision.
Interventions - an empirical classification
I will classify interventions based on an empirical study of what is effective. This original paper reports the types of interventions with evidence to support them.
Exercise - cardio-respiratory.
The term exercise has two meanings when used in rehabilitation: any physical activity that leads to an increase in heart and breathing rate; and the exercise of practising a specific activity such as walking or writing. This part concerns cardio-respiratory exercise – which may also be practising an activity simultaneously.
Much evidence shows that exercise benefits fatigue, multiple sclerosis, back pain, fibromyalgia, other functional disorders, arthritis, chronic pain, and most other conditions. There is little or no evidence that exercise can cause harm.
Exercise - practice.
There is also a wealth of evidence that practice at an activity leads to improvement. This evidence should not be surprising because it is how we learn as children and adults. It is often termed ‘task-specific training’. You must recognise that the benefit primarily accrues to the specific tasks; practising typing is unlikely to benefit playing the piano even though the activities are similar. Practice also helps cognitive and non-physical activities.
Education and self-management skills
There is also good evidence to support education about the patient’s disease or condition and how the patient can manage the situation.
There is no good description of the actual content of psychosocial support, but many studies stating that they gave psychosocial support found the intervention effective. Most evidence likely concerns actions to improve a patient’s emotional state or resilience.
Tailored individual interventions.
Almost all studies on rehabilitation as an intervention refer to giving interventions that are patient-centred and individualised to the patient. Tailoring the intervention applies to various interventions, such as providing a suitable prosthesis, orthosis, or a drug for a specific problem such as spasticity. Still, it will also apply to all the interventions discussed above.
Interventions - a systematic approach
A second way to approach interventions is to consider interventions for each domain of the holistic biopsychosocial model of illness that I have described here. This approach reduces the risk of overlooking an intervention, and once you are familiar with the model, it should take a little time. I will illustrate the systematic approach.
If the patient has an underlying disease, and you must remember that up to 20% of patients may not, you must ensure the disease has been treated as effectively as possible. Often the referring service will have done this. However, one cannot assume this because it is only sometimes valid. In addition, any continuing treatment may need monitoring or adjusting and may have complications that the rehabilitation team must be aware of. The rehabilitation service ignores considering disease-specific treatment at its peril.
All expert rehabilitation services need to manage impairments at an excellent level. The interventions include:
- direct pharmacological treatment and surgical interventions
- teaching the patient how to reduce, if possible, or otherwise manage and adapt to an impairment
- using assistive technology such as orthoses and functional electric stimulation to reduce the impairment or its effects
I suspect that more interventions focus on activities than any other domain. There are three main types of intervention:
- learning and practising an activity, for example, walking or using cutlery
- learning how to achieve the activity in an adapted way, for example, walking with a mobility aid or feeding oneself using only one arm
- learning how to achieve the same goal through a different activity, for example, using an electric wheelchair or a voice-controlled computer
In contrast, I suspect less attention is paid to this domain than it deserves because it is more complex and challenging. It requires more time to achieve than most programmes are funder for, and it depends upon other organisations and people. Further, once the patient realises that new social networks and roles are needed, they will be more engaged.
For patients who cannot return to previous employment and other daily routines, the importance of structuring time cannot be overstated and is often completely overlooked. The effect of retirement and unemployment on healthy people illustrates the importance of structuring time. One must consciously set up mechanisms such as alarms, printed daily schedules, routines and so on to avoid the patient slipping into an inactive and depressed state.
Intervening in the social context is not easy but needs to be considered. One can help the person by discussing and suggesting new or altered opportunities to develop meaningful (to them) social roles. Often one of the barriers is the attitude of other people close to them, such as family or friends, who may see suggestions that the person considers new or altered roles as the rehabilitation team “giving up”. Thus a crucial second area of intervention is with the key people who may influence the patient.
One sometimes contentious area is the possible move into sheltered or residential care, not because it offers better or cheaper care but because it offers a built-in social context. For example, one of my patients who had been in the Royal Airforce for many years wanted to move to a care home run for veterans. I supported this, but his social worker was resistant, arguing that it was always better for someone to live ‘in the community’. The social worker should have noticed that his preferred community was not an Oxfordshire village, it was other veterans, and none lived where he did.
Most rehabilitation teams will be well aware of acting on the physical context. The examples are endless: adapted clothing, small equipment, building alterations, prostheses or orthoses, moving house, adapted cars, hearing aids etc.
Although one might initially consider personal context an unalterable given, one can alter it. Personal context encompasses such phenomena as beliefs and expectations, and interventions such as cognitive behavioural therapy, education, and motivational interviewing alter the personal context. Interventions within this domain may be as effective as any other intervention.
I have reviewed what I mean by intervention on this page and how they may be classified empirically and using a systematic approach based on the biopsychosocial model. I have not given details on any specific interventions or reviewed how you should identify interventions. It is unrealistic to cover all possible interventions, and the list would rapidly become out-of-date. On the other hand, I have raised some issues concerning terms such as treatment, care, therapy, and intervention. I suggest that, as in almost all other areas of healthcare, clear boundaries are not possible. Carlo Rovelli wrote, “Words are never precise: the variegated cloud of meanings that they carry about with them is their expression power.” This statement was in the context of information as part of quantum mechanics in Helgoland (page 90), but it applies universally.