Evidence-based name

This page will solve two problems facing rehabilitation: what constitutes the key features of rehabilitation; and “does rehabilitation work?”. It starts from a third question, what does the word rehabilitation mean in a healthcare context? One way to determine the meaning of a word is to study how it is used. We all do that as we learn new words. So I set out to discover the meaning of rehabilitation, when used in a healthcare context, by finding all the research I could where the authors stated that they were studying rehabilitation. I restricted my search to studies that found a benefit, as I also wanted to discover what features characterised successful rehabilitation. This page outlines what I found. The detailed evidence is published here. The description is summarised in a graphic here.

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

I should emphasise a few things. There were many more studies, even just systematic reviews, that the number given in the paper. There seemed little point in overdoing it! I used the Cochrane Library as my primary source, though I looked elsewhere to cover some topics . Cochrane reviews were used in preference to others, unless the Cochrane review was much older.

One set of findings were 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.
  • whatever the normal trajectory 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, what ever rehabilitation is, it is not defined by the patients seen or able to benefit.

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 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 mentions process (or I missed the mention or the studies). Nonetheless, explicitly or implicitly, the following features of 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 patient-centred interventions (treatments) recorded fell into four main groups that were found 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.

The most important aspect of treatment was that it had to be tailored to the needs and wishes of the patient. This seemed to encompass two ideas:

  • the four groups of interventions listed above needed to be tailored to the patient. If 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 ….”
  • An addition set of interventions outside the group (discussed in the next paragraph)

Other aspects of rehabilitation.

My review of the evidence did not discover evidence relating to some other important characteristics of rehabilitation. Maybe I did not find it. Maybe I overlooked it. Maybe it is so obvious that no-one has researched or published it.

For example, there has been no mention of acting on contextual factors. One very important role of rehabilitation services is to recognise when someone might benefit from being given a wheelchair, or an environmental control system; this would be difficult to demonstrate in research. Almost all orthoses, prostheses, and other assistive technologies are tailored to the individual and are included within the ‘tailoring treatment’ group.

There is also no mention of advising on long-term care and support needs, yet t his is an increasingly important role as the number of severely dependent people remaining alive increases. Consider the large number of people entering a prolonged disorder of consciousness each year. (here)

Summary/conclusion

The evidence reviewed allows everyone to appreciate the meaning associated with the word rehabilitation. It also shows that rehabilitation does indeed work and that it does so for everyone who has a persisting limitation on their social engagement or functional activities. It emphasises the need for multi-disciplinary teams with expertise in rehabilitation.

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