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 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 the components of the International Classification of Functioning, Disability and Health that are contributing to the overall lack of optimal functioning with the overriding goal of rehabilitation being to utilise appropriate interventions that allow the individual to optimise their function.

Outcome Orientated

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

• Prevention of the loss of function
• Slowing the rate of loss of function
• Improvement or restoration of function
• Compensation for loss of function (compensatory strategies)
• Maintenance of current function

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

Classification of Interventions

Rehabilitation interventions are hugely diverse and except in rare instances require the involvement of many different health and rehabilitation professionals and cross multiple disciplines often at the same time, which as a result make the classification of rehabilitation interventions quite complex. It is this complexity that makes classification of rehabilitation interventions a challenge, and as result there is still no classification that has been universally accepted across all fields of rehabilitation currently, despite several attempts made to develop a classification system to fully describe rehabilitation interventions. Levack and Dean have outlined three key reasons for this;

1. Firstly, rehabilitation interventions are not only about the intervention itself and what the healthcare professional does, but are significantly influenced by experience and relationships and how the healthcare professional engages and interacts with the individual and other significant people in their lives. It is within these interactions that rehabilitation interventions now work towards changing how patients think about their disability, their motivation for rehabilitation, their self-efficacy and the way they participate within therapeutic activities.
2. Secondly, generally most rehabilitation interventions do not work on one component or domain alone but rather involve a number of interacting components.
   • Example; An occupational therapist may use a simple cooking activity to help an individual regain skills in activities of daily living following a stroke. While the primary focus may be on cook, the activity itself also incorporates include strengthening of weak muscles in a hemiplegic arm and leg (standing in the kitchen, lifting and using kitchen utensils; and bending and reaching), retraining of balance (standing and moving around the kitchen), cardiovascular exercise conditioning and fatigue management, 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 on the nature of stroke and how to adjust for loss of function on return home, as well as providing general emotional counselling and support. Furthermore, a collaborative approach can be taken to address the patient’s various functional limitations by using the same task but combining the session with another member of their rehabilitation team (e.g. the speech language therapist or physiotherapist).
3. Finally, rehabilitation interventions can be provided for within a group environment or individually across a broad range of rehabilitation settings from a hospital environment, to primary care and community based settings such as the home, work, local gym etc. Each approach has its own advantages and disadvantages but no matter what setting or structure is involved rehabilitation should always be designed to meet the individual needs of each patient. Given this being able to adapt, modify, create and be flexible are vital skills required by rehabilitation professionals in order to be able to adapt interventions and therapeutic activities depending not only on the particular spectrum of impairments that someone 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 their personality and personal interests.
   • Example; An athlete following an ACL injury may start their early rehabilitation individually within the physiotherapy clinical for individual assessment and treatment. This may also be incorporated with some group based activity with team mates within the Gym, where they get to train with team mates while working on their own specific rehabilitation programme and goals. As they progress through their rehabilitation programme and work towards return to play, rehabilitation may continue to include both individual, small group and team based activities, but may be field or court based to prepare for return to competition.

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