|CHAPTER 2: REHABILITATION
|Year : 2019 | Volume
| Issue : 2 | Page : 19-24
2.2 Rehabilitation: Rehabilitation as an intervention
John L Melvin
Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
|Date of Web Publication||11-Jun-2019|
Prof. John L Melvin
Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Melvin JL. 2.2 Rehabilitation: Rehabilitation as an intervention. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:19-24
| Introduction|| |
As described in the previous chapter, the WHO World Report on Disability defines rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments.” Rehabilitation by this definition is an intervention composed of multiple components that are themselves interventions.
Rehabilitation as an intervention is usually complex and multifaceted. Its interventions address issues related to body functions and structures, capacity for activities, performance of participation activities, environmental factors, and personal factors. Most individuals participating in rehabilitation require interventions addressing many or all of these International Classification of Functioning, Disability and Health (ICF) components. In addition, one or more of these components may have more than one functioning category contributing to the overall lack of optimal functioning [Table 1]. Appropriate rehabilitation interventions address all or most of the factors contributing to the lack of optimal functioning and thus are comprehensive.
|Table 1: Case example of problems requiring rehabilitation interventions organized by the International Classification of Functioning, Disability and Health component|
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Rehabilitation professionals organize their interventions to target the many factors contributing to the lack of optimal functioning (see chapter 1). Addressing all of them requires a wide range of expertise and competencies that exceed those possible for a single discipline. Thus, there are multiple disciplines of rehabilitation professionals, each addressing its own part of the spectrum of measures needed to achieve the comprehensive goals of rehabilitation [Table 2]. Rehabilitation interventions except in rare instances require the involvement of multiple disciplines and from this perspective are multidisciplinary in nature.
|Table 2: Professional disciplines providing rehabilitation interventions|
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The involvement of many disciplines in the rehabilitation process requires individual rehabilitation professionals to work together as a team. This makes necessary open and planned communication regarding the status of the patients, the goals of the patient programs and the interventions needed by the patients to achieve their goals. After input from the individual professional team members, the patient and appropriate family members, the team as a whole develops a plan of care designed to achieve the patient's goals. In patients with active and significant health conditions, the teams are usually led by a physician who specializes in rehabilitation medicine. The dynamics of individual teams vary, but the ultimate goal for the team is to provide a coordinated rehabilitation program. Further, this model of joint planning, decision-making, and goal setting is an example of interdisciplinary practice, where each of the professions understands and respects the contributions of the others. This is in contrast to a multidisciplinary approach described as when each discipline may work in parallel and with potentially different goals. The major role of the patients in determining their goals and interventions makes rehabilitation a patient-centered intervention.
Rehabilitation may vary in its intensity, generally measured by the frequency and duration of individual interventions or treatment sessions. For instance, in the United States, patients in rehabilitation hospitals are expected to receive at least 3 h per day of therapy and 5 days per week. Depending on the patient's needs, this 3 h of therapy per day may be comprised physical therapy, occupational therapy, and/or speech therapy. The intensity of therapies best for individual patients varies by their needs for improvement in functioning and by their tolerance of therapeutic activities. Different rehabilitation settings may vary in their capacities to provide specific intensities of therapies. For instance, in the US, rehabilitation hospitals provide the most intense therapy programs.
Rehabilitation is outcome oriented. Its core outcomes include preventing the loss of function, slowing the rate of loss of function, improving and restoring function, or compensating for lost function. Rehabilitation interventions may target outcomes for any or all of the three areas of human functioning: impairment, capacity for activities, and performance of activities and participation. Common functional goals for patients with the recent onset of disability include those related to mobility, self-care, communication, and cognition. Later, goals focus more on education, work, employment, socialization, and quality of life.
Rehabilitation is an essential component of care throughout the full continuum of care. This includes acute care, general and specialized postacute rehabilitation, and general and specialized outpatient rehabilitation. It often is a component of care in the practices of physicians not specializing in Physical and Rehabilitation Medicine, especially primary care and geriatrics. The functioning status, rehabilitation interventions, and outcome assessments are likely to vary during different stages of the care continuum, requiring appropriate rehabilitation approaches and expertise for each.
Rehabilitation is a process, generally composed of a series of cycles having short-term goals that represent steps toward the goals of a long-term rehabilitation plan. Each cycle has the following components: (1) assessment of the functioning status of potential rehabilitation recipients; (2) identification of the functioning categories with potential for improvement; (3) selection and quantification of the goals of the intervention program; (4) assignment of treating professionals to the areas of needed improvement that match their expertise; (5) implementation of the assigned interventions; and (6) evaluation of the results of the interventions. At the end of each cycle, the process begins again until there is no significant improvement in functioning from the application of the rehabilitation interventions.
A formalized process known as the Rehab-Cycle is available for the practical implementation of these cycles. Rehab-Cycle uses four phases: assessment, assignment, intervention, and evaluation.,,,,,, It combines the first three of the components described above into the phase of assessment. The forms and procedures of the Rehab-Cycle approach can organize and improve the decision-making associated with providing rehabilitation programs. [Figure 1] shows the cyclic relationship of these phases and the related ICF documentation tools.
|Figure 1: The Rehab-Cycle® and the corresponding International Classification of Functioning, Disability and Health-based documentation tools|
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| Theoretical Case Report|| |
KL is a 19-year-old male involved in an auto accident 12 weeks before his evaluation for admission to a specialty spinal cord injury center. His injuries included fractures of the T3 vertebrae and the right radius. Following the accident, he had total loss of sensation and motor function below the T3 level.
Assessment at admission – the International Classification of Functioning, Disability and Health Assessment Sheet
[Figure 2] displays the ICF Assessment Sheet the staff of the specialized spinal cord injury center completed as a part of the admission process (12 weeks after injury). This sheet presents the results of a comprehensive assessment of all ICF components, including functioning, environmental factors, and personal factors. It includes information from the perspectives of the health professionals and the patient in different sections.
|Figure 2: International Classification of Functioning, Disability and Health Assessment Sheet|
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Assessment at admission – the International Classification of Functioning, Disability and Health Categorical Profile
[Figure 3] shows a visual representation of KL's functioning at the time of this admission evaluation using the ICF Categorical Profile. The profile identifies the ICF categories relevant to the patient's functioning and provides quantification of their level of problem. It also includes both long- and short-term goals similarly quantified.
|Figure 3: International Classification of Functioning, Disability and Health Categorical Profile|
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[Figure 3] was reproduced with permission from the monograph: Swiss Paraplegic Research. ICF case studies. Translating interventions into real-life gains – a Rehab-Cycle approach (Internet) where it was labeled as [Figure 4].
|Figure 4: International Classification of Functioning, Disability and Health Intervention Table|
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To complete the categorical profile, the rehabilitation team, considering the patient's input, identifies long- and short-term goals, the ICF categories related to achieving these goals through targeted interventions, and quantified goal values for each category.
Intervention targets are ICF categories for which the team has identified goals and which it intends to address during the intervention phase of the Rehab-Cycle®. The following codes indicate the relationship of each intervention target to the different levels of goals. These codes are in the column marked “Goal relation:”
- G = Global Goal: it is the highest-level goal that a person aims to achieve and refers to the intended outcome after successful completion of rehabilitation
- SP = Service-Program Goal: it is an intermediate goal that a patient aims to achieve and refers to an endpoint of a specific program of rehabilitation
- “1,” “2,” and “3” refer to cycle goals 1, 2, and 3, respectively; a cycle goal is a short-term goal that a person aims to achieve. Several cycle goals are the “stepping stones” toward achieving the corresponding service-program goal.
A goal value for each targeted ICF category is necessary to evaluate whether its goal is achieved following the intervention. The rehabilitation team generally establishes goal values only for those ICF categories that are intervention targets and have goal relations.
Assignment and Intervention – the International Classification of Functioning, Disability and Health Intervention Table
[Figure 4] is the ICF Intervention Table developed by the rehabilitation team for KL. It includes all of the ICF categories the team has selected as intervention targets, the interventions themselves and the professionals the team assigned to provide the interventions. It also records the initial quantified level of functioning for each intervention target, the expected goal value, and the actual value after a cycle of intervention.
Evaluation – the International Classification of Functioning, Disability and Health Evaluation Display
[Figure 5] shows the ICF Evaluation Display the rehabilitation team completed for KL after 4 weeks of treatment (16 weeks after onset) in the spinal cord injury specialty treatment center. It includes the initial quantified functioning levels of the ICF categories selected as intervention targets and the comparable functioning levels after 4 weeks of intervention. The ICF Evaluation Display includes the goal relation and goal value of each of the ICF categories it lists. In addition, it has a column that indicates whether the functioning level of each ICF category after intervention met its goal value. Changes in functioning after interventions are not necessarily the result of the interventions so require analyses that consider other factors such as spontaneous recovery as well. However, the information in the ICF Evaluation Display is useful to the rehabilitation team as it considers whether to proceed with further interventions in the treatment center or discharge to the community.
|Figure 5: International Classification of Functioning, Disability and Health Evaluation Display|
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This case report utilizes the Rehab-Cycle® and its documentation tools to demonstrate the specific elements of rehabilitation as an intervention. It includes evaluation and re-evaluation in addition to specific interventions and the professionals who provide them. The monograph: Swiss Paraplegic Research. ICF case studies. Translating interventions into real-life gains – a Rehab-Cycle® approach provides additional detail in the use of the Rehab-Cycle®.
| Summary|| |
Rehabilitation is an intervention focused on enabling the optimal life participation of those with or likely to experience disability. It is a comprehensive approach that addresses the multiple categories of functioning and related environmental and personal factors that contribute to disability. The diversity of factors contributing to disability requires multiple professional disciplines to provide the rehabilitation interventions needed for optimizing function. For effectiveness, their efforts require coordination and an interdisciplinary approach. Rehabilitation as an intervention is person centered, in that it addresses the specific needs of the individual, focusing on those issues they see as important. Rehabilitation is outcomes oriented, using levels of functioning as its index of success. Operationally, it is a series of cycles with specific strategies and targeted outcomes. Rehabilitation is an essential component throughout the full continuum of care. This includes acute care, general and specialized postacute rehabilitation, and general and specialized outpatient rehabilitation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]