Rehabilitation Interventions

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Original Editors - Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Oyemi Sillo, Cindy John-Chu, Kim Jackson, Tarina van der Stockt, Vidya Acharya, Rucha Gadgil, Lucinda hampton and Ashmita Patrao      

Introduction

If we consider the definition of rehabilitation " 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”, then rehabilitation is in effect composed of multiple components to address issues related to all domains within the World Health Organisation's  International Classification of Functioning, Disability and Health (ICF) including; body functions and structures, capacity for activities, performance of participation activities, environmental/contextual factors, and personal factors. Most individuals participating in rehabilitation require interventions addressing one, many or all of components of the ICF that are contributing to the overall lack of optimal functioning, with the goal of rehabilitation being to utilise appropriate interventions that allow the individual to optimise their function.

As a result rehabilitation involves a hugely diverse range of interventions, across multiple disciplines. While several attempts have been made to develop a classification system to fully describe or outline these interventions currently there is no one taxonomy that has been universally accepted across all fields of rehabilitation. What is apparent is that the classification of rehabilitation interventions is complex. There are a number of reasons for this.

First, almost all rehabilitation interventions are experience based and relationship based (Hart, 2009). In other words, rehabilitation interventions depend not only on what health professionals do, but also on how they engage with patients and the significant other people in their lives and, reciprocally, how patients engage with them. Interventions can involve not only modalities to influence health and function but also can be directed toward changing how patients think about their disability, their motivation, their capacity for achieving goals (i.e. their self-efficacy) and the way they undertake therapeutic activities.

Second, most rehabilitation interventions involve a number of interacting compo- nents. For example, an occupational therapist may use a simple baking activity to help an older adult regain skills in activities of daily living after a stroke. However, the activity itself may include strengthening of weak muscles in a hemiplegic arm and leg (lifting and using kitchen utensils; bending and reaching), retraining of balance (moving around the kitchen), cardiovascular exercise conditioning and fatigue man- agement, training in the use of assistive technology (mobility aids and adapted kitchen implements) and cognitive retraining (following a recipe; safe use of an oven). Concurrently, the occupational therapist may also use the same therapy session as an opportunity to provide some education for the older adult on the nature of stroke and how to adjust for deficits in function on return home, as well as providing general emotional counselling and support. Furthermore, the occupational therapist may conduct their treatment as a combined session with another member of their rehabili- tation team (e.g. the speech language therapist or physiotherapist), taking the oppor- tunity to work collaboratively to address a patient’s various functional limitations.

Third, rehabilitation interventions involve a considerable degree of creativity and flexibility when tailoring treatments to meet the individual needs of patients. Rehabilitation is a problem-focused intervention. The specific nature of therapeutic tasks are continually adapted by rehabilitation professionals depending not only on the particular spectrum of impairments that a patient might present with, but also on the specific goals of rehabilitation for that individual, the environmental context under which a patient is performing targeted activities, and on the personality and personal interests of the patient. Rehabilitation interventions can also be provided individually or in groups, and in different clinical settings such as a rehabilitation gym or in ‘real world’ environments in the community, with different benefits and disadvantages to each approach.

Rehabilitation interventions except in rare instances require the involvement of multiple disciplines and from this perspective are multidisciplinary in nature. Rehabilitation may vary in its intensity, generally measured by the frequency and duration of individual interventions or treatment sessions. 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.

Outcome Orientated

Rehabilitation interventions are generally outcome oriented, in that the goals developed are based on achieving a specific outcome. These core outcomes focus on four broad areas that include;

• preventing the loss of function,
• slowing the rate of loss of function,
• improving and restoring function,
• or compensating for lost function.[1]

Rehabilitation interventions may target outcomes for any or all of the three areas of human functioning:

1. impairment,
2. capacity for activities, and
3. 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 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:

• assessment of the functioning status of potential rehabilitation recipients;
• identification of the functioning categories with potential for improvement;
• selection and quantification of the goals of the intervention program;
• assignment of treating professionals to the areas of needed improvement that match their expertise;
• implementation of the assigned interventions; and
• 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.

Rehabilitation interventions can however be described in terms of the following;

• Situations in which actions are taken (context)
• Goals the actions intend to achieve
• The level at which the intervention is acting
• Specific therapeutic procedures
• Knowledge and skills required
• Any equipment required
• Other concomitant procedures
• Underlying theories/principles guiding actions

Package of Rehabilitation Interventions

The World Health Organisation consider rehabilitation a core health service for individuals with health conditions throughout the life course, and across the continuum of care, such as children with developmental disorders, people with chronic conditions and living with the consequences of injuries or older people. Given this is it vital that all countries across the globe are equipped with both the technical guidance to establish and strengthen rehabilitation service delivery in line with their specific population needs, and also be able to identify and prioritise what rehabilitation interventions should be integrated into the health system, and the resources required to deliver them safely and effectively.

The essential package of interventions, based on both the International Classification of Functioning, Disability, and Health and the International Classification of Health Interventions was an initial attempt to compile rehabilitation interventions into a minimum essential set of services. This initial package of rehabilitation interventions was not mapped to a specific diagnose or condition but rather was developed to be utilised in the context of many health conditions, it also was not all encompassing and did not incorporate many important adjuncts commonly used in rehabilitation such as prescription of medication. Similarly the package also did not indicate specific rehabilitation disciplines that will be held responsible for providing the interventions, so as to be applicable to a range of settings and levels of rehabilitation workforce capability. Although targeted at resource-constrained or low resource settings, those countries with greater resource availability were encouraged to expand on the scope, quality, and availability of interventions beyond those essential interventions identified in the package. In this initial Essential Package of Interventions, a broad spectrum of skills, largely dependent on the complexity of the needs of the person (such as the presence of comorbidities, the severity of the health condition, and other personal and environmental factors), were needed to deliver many of the interventions, with the effectiveness heavily based on the on the skills, experience, and clinical reasoning of the providers .

Resources

World Health Organisation Package of Rehabilitation Interventions