This page considers how a rehabilitation team should analyse a patient’s situation holistically. This page gives an overview. It links to four further pages illustrating mode detailed analyses, each concentrated a separate domain within the biopsychosocial model of illness. If you wish to have a graphic of the model open in a new tab, then click here.
When analysing a complex situation, an expert who has done it many times can often see the most likely explanation and way forward with consciously working it out. While this is obviously good, providing a quick answer, there are problems. The answer is given, but has to be accepted on trust as often there is no obvious explanation how the analysis occurred. The explanation may seem well-supported, but it has not been tested against other possible explanations. Experts can be wrong.
It is also self-evident that expertise develops over time, and people need to develop expertise. The approach used in neural networks is to let the network reach an answer, and then to confirm or refute the answer. This approach can be used by people too, with the expert ‘training’ the other person. It formed the basis of much medical training in the past. But this is a slow method of acquiring expertise, and if the expert is wrong, then it is also faulty.
It helps to have a systematic approach. One approach is given here. This approach should be applied to each of the four domains of the biopsychosocial model that apply the person: disease, symptoms (experiences), disability, social participation. The order does not matter, but it is probably easiest to start with disabilities. It will be illustrated in more detail in the accompanying pages.
The first set of questions relate to consistency. The essential question is, “Are the patient’s preserved and limited or lost phenomena in this domain consistent with the known preserved, limited or lost phenomena in each of the other three domains?” For example, is the inability to walk at all consistent with a diagnosis of a right middle cerebral artery area stroke two days ago? The answer would usually be yes. But it the diagnosis was of a small lacunar stroke two years ago, the answer would be no.
As another example, is the observed and reported dependence on others for dressing consistent with a diagnosis of mild cardiac angina, whereby the patient can walk up and down stairs? Probably not! However further assessment might reveal an episode of cerebral hypoxia causing quite marked apraxia.
If there are areas where the relationship appears different from that expected, then the assessor needs to look further. This will involve considering other disease, either in addition or even that the main diagnosis is incorrect; other impairments being present; or exacerbating environmental factors; or personal factors relation to expectation, belief, motivation etc. If someone’s performance seem usually better than expected, then the other information needs review.
The second set of questions relate to factors that may many be influencing the domain being considered, modifying the degree of alteration observed in a phenomenon (e.g. making pain less or more that it might otherwise be). Closely related to this, factors many be maintaining a problem which might otherwise lessen.
And the third set of questions relate to the future, both prognosis and suggesting areas for intervention. For example, if anxiety that exercise might precipitate a second stroke is reducing the amount a patient practises walking after stroke, then an educational and/or psychological intervention might be needed.
As suggested initially, it is probably rare to ask each question about each observation. On the other hand, failing to be curious, and failing to ask any questions makes the whole process of data collection pointless. The intention of the assessment is to gain the fullest understanding possible. This will not arise if data are just collected ‘as a routine’; the relevant data may not be collected, or so much data may be collected that it is impossible to discern what needs attention.
Therefore, the person undertaking the assessment should always start with some hypothesis (idea) as to what the problems are, how they arise, and what can be done. Then, as data from a domain are collected to try and clarify matters, the person would think about the data as they are collected:
- are the data consistent with what I know already, or do they raise questions?
- are these items of data having an influence on other areas of data and/or are other areas of data having an impact on this set of data?
- do the data I have just collected suggest a possible treatment and/or suggest the likely situation in a few weeks’ or months’ time?
These four pages explore the assessment of the four clinical, patient-centred domains of the model in more detail:
This comes first for several reasons. It is part of a logical order, working from inside the body out into the whole world. Disease not only can be cured, sometimes, but it also determines (a) what problems are more or less likely to arise and (b) the ‘prognostic field’ for the patient’s problems. It is also placed here to emphasise that reviewing disease is as important as reviewing other domains, no more but also no less. To look, click here.
Impairment (symptoms and signs)
This is, perhaps, the most complex part of the analysis. There are three different concepts included within the word impairment when it is used within rehabilitation:
(a) structural loss,
(b) use of a word to represent a construct, and
(c) patient experience.
(a) an essential bridge between pathology and disability,
(b) a representation of the clinician’s interpretation of observations, and
(c) a representation of the patient’s experience.
To explore further, click here.
Disability is the focal point of the rehabilitation process, and analysing disability is a central skill – but not the only one. It is a first step on what may be a short and easy journey, or a long and complex one. If the analysis is flawed or incomplete, the journey may be a cul-de-sac and waste the patient’s time, and healthcare resources. Though, at first sight, the consequence of an incorrect ‘diagnosis’ (understanding) of disability may appear less severe that in the case of an incorrect diagnosis of disease, an incorrect disease diagnosis will rapidly become evident but an incorrect rehabilitation diagnosis may only become evident slowly. To read more, click here.
Social functioning (participation)
This area is the most difficult to specify, categorise, and measure but it is also the most important area from a patient’s perspective. Moreover, it is likely that a failure to consider social functioning during rehabilitation will not only lead to a less effective and less efficient process, but will also be associated with greater long-term societal cost (health and social services combined). Patients who have inadequate social function, with too few networks and relationships (in their eyes), are more likely to be less healthy and use more healthcare resource. To read more on analysis, click here.