Introduction to Basic Rehabilitation Techniques

Original Editors - Naomi O'Reilly and Jacquie Kieck

Top Contributors - Naomi O'Reilly, Ewa Jaraczewska, Jess Bell, Tarina van der Stockt, Tony Lowe, Bruno Serra and Lucinda hampton      

Introduction

Rehabilitation is a concept that is widely discussed globally. This is by no means unexpected since approximately 1.5 billion people worldwide live with a form of disability, accounting for over 15% of the world population. Furthermore, according to a recent report, 2.41 billion individuals worldwide live with conditions that impact their functions in daily life and would benefit from rehabilitation services - this equates to 1 in 3 individuals requiring rehabilitation services throughout their illness or injury.

The term "rehabilitation" is used in many different contexts, but the general underlying definition is based on the idea that each person has the right to be an active participant and expert in identifying their needs and making decisions on their health care. Currently, there is no universal definition or understanding of rehabilitation, and it is portrayed in many ways depending on the context, including as a development issue, disability issue, health issue, human rights issue, substance abuse issue, and security issue, to name a few.

If we consider the definition of rehabilitation promoted by the World Health Organization 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”, then rehabilitation is a "set of interventions designed to optimise functioning in individuals with health conditions in interaction with their environment". In effect, rehabilitation is composed of multiple components or "interventions" to address issues related to all domains within the World Health Organization's International Classification of Functioning, Disability and Health (ICF), including body functions and structures, capacity for activities, the performance of activities, participation, environmental/contextual factors, and personal factors.

International Classification of Functioning, Disability and Health (ICF)

The International Classification of Functioning, Disability and Health (ICF) is a biopsychosocial model of functioning, health and disability. Using standard language to define and measure disability, the ICF helps to explain how a person's body problems and social circumstances affect their functioning within their environment.

Figure. 1 International Classification of Functioning, Disability and Health (ICF) Model

In the ICF model, a person is viewed in terms of their health conditions, body functions and structures, activities and participation, and environmental and personal factors.

• Health Condition: "an umbrella term for the disease, disorder, injury, trauma".
• Body Functions: "physiological functions of the body system, including psychological functions".
• Body Structures: "anatomical parts of the body, such as organ, limbs and their components". Example include weight bearing limitations following a surgery or trauma.
• Activity: "execution of a task or action by an individual". Activity limitations describe the problems or issues at the level of the individual.
• Participation: "involvement in a life situation". Participation restrictions are problems the individual may experience in their life situation or within an environmental context.
• Environmental Factors: the "physical, social and attitudinal environment in which people live". Environmental factors can be considered a barrier or facilitation in terms of how they affect one's functioning. An example include building accessibility for a wheelchair user.
• Personal Factors: the "particular background of an individual's life and living".

You can learn more about the ICF components and ICF qualifiers here.

Health conditions can refer to disease (acute or chronic), injury or trauma, which may also include other circumstances such as genetic predisposition, stress, pregnancy or ageing. Anyone with a health condition who experiences some form of limitation in body functions and structures, such as cognition, emotion, vision, communication, motor and mobility, may need access to rehabilitation. As such, rehabilitation interventions should be guided by the ICF Model and incorporate techniques that allow for the assessment and identification of problems in all areas of the ICF. This should then be followed by a selection of interventions that address impairments in body functions and structures, activity limitations and participation restrictions, considering both personal and environmental contextual factors that impact functioning.
Most individuals participating in rehabilitation require techniques and interventions addressing one, many or all of the components of the ICF that contribute to reduced functioning. The overriding goal of rehabilitation is to utilise appropriate techniques and interventions that allow the individual to optimise their function. Given this, individuals with health conditions or injuries may require rehabilitation at various points across their lifespan.

The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors, which include:

• the aetiology and severity of the person’s health condition
• the prognosis
• how the person’s condition affects their ability to function in their environment
• the individual’s identified personal goals and what the person wants to achieve from the rehabilitation process

The comprehensive and holistic nature of the ICF makes it extremely useful in clinical practice. The primary purpose of applying the ICF in clinical practice is to establish a common language for defining health and health-related states between providers. It can enhance decision-making among health and social care professionals. The ICF's holistic approach is essential for making more informed assessments, developing effective interventions, and achieving good patient outcomes.

Clinical Assessment

Assessment, typically the first step in the rehabilitation process and arguably one of the most important elements, has always been a key part of the rehabilitation process. It has been viewed as a critical element in enhancing rehabilitation outcomes. Rehabilitation interventions are only as good as the assessment on which they are based. The clinical assessment provides information to guide our decision-making in formulating goals and selecting appropriate rehabilitation interventions. As such, our assessment and choice of rehabilitation techniques underpin much of what we do within rehabilitation.

Assessment has many meanings, even within the local rehabilitation context, but it effectively encompasses collecting and evaluating patient data to guide the development of patient-centred goals. Rehabilitation is a problem-solving process. The first stage in any problem-solving process is to understand the problem in detail:

• what is the fundamental difficulty, which may or may not be the same as the initially identified problem;
• what are the critical factors related to the problem;
• what factors, if any, might help identify measures that could improve the situation; and
• what factors help decide which activities should be undertaken and/or should not be undertaken?

While the clinical assessment forms the initial foundation for the rehabilitation process, it is also an ongoing and continuous process. It should occur throughout the rehabilitation process to monitor for changes in the patient and guide modification of the rehabilitation plan. As such, the rehabilitation professional needs to know what assessment techniques and tools are available, how and when to use them, how to choose the best one, how to interpret the data they provide, and equally importantly, they also need to know when not to use them.

Selection of Rehabilitation Techniques and Interventions

As a highly diverse field, rehabilitation uses many interventions to facilitate functional change. An effective, efficient, and patient-centred rehabilitation intervention "requires a system for specifying treatments that describes specific clinician actions in rehabilitation and links them to the desired functional changes in a structured, meaningful way."

The Medical Research Council has published guidance on research related to developing, evaluating, and implementing complex interventions to improve health. It recommends considering key questions when developing a rehabilitation intervention, particularly in the case of complex healthcare. The guidance was intended mostly to help researchers choose appropriate methods within research and research funders to understand the constraints on evaluation design. However, the first four questions (listed below) are also applicable and relevant to service managers and rehabilitation professionals to guide their selection of appropriate rehabilitation techniques and interventions.

1. Are you clear about what you are trying to do, what outcome you are aiming for, and how you will bring about change?
   • This is applicable whether we are researching the impacts of an intervention or selecting a technique or intervention for use in our daily clinical practice as rehabilitation professionals. When considering what rehabilitation techniques and interventions to use, the patient's wants and needs are key. Their rehabilitation goals should be central to what we are trying to achieve when selecting our intervention. Providing patient-centred care that incorporates a patient's cultural considerations, needs, and values is a necessary skill for best practice services.
2. Does your intervention have a coherent theoretical basis that has been used to develop the intervention?
   • Evidence-based practice is "the integration of best research evidence with clinical expertise and patient's values with consideration for all circumstances related to patient assessment and management, practice management, and health policy decisions on making". Rehabilitation professionals recognise the use of evidence-based practice as central to providing high-quality care and decreasing unwarranted variation in practice. The rehabilitation professional's knowledge and skills are key to this evidence-based process. The personal scope of practice consists of techniques and interventions undertaken by them that are situated within their unique body of knowledge where the individual is educated, trained, and competent to perform that activity. The use of clinical decision-making and judgment is key. Since the implementation of evidence-based practice in rehabilitation, there have been major advances in the quality of health care and patient outcomes.
3. Can you describe the technique or intervention fully so that it can be implemented properly for the purposes of your evaluation and replicated by others?
   • This is, of course, particularly vital in research, to ensure that studies can be replicated or further developed within clinical practice. However, it is also important as it enables other rehabilitation professionals working with a person to understand the rehabilitation techniques and interventions being used. Moreover, if a person's rehabilitation is being transferred to another team member, this clinician will be able to evaluate and continue to provide and build on effective rehabilitation interventions.
4. Does the existing evidence suggest that it is likely to be effective or cost-effective?
   • Ensuring we choose rehabilitation techniques or interventions that are both effective and cost-effective can be very important, particularly when selecting and developing techniques or interventions for use within low-resource settings. We know in many cases, there is often more than one technique or intervention that can support a specific goal. Therefore, as clinicians, we need to be able to weigh up the technique or intervention options available. We must consider the effectiveness of the technique or intervention to optimise the function of the individual but also the cost implications of this intervention, both for the individual (particularly where the individual has to cover the cost of the intervention) and/or the rehabilitation service.

Resources

• International Classification of Functioning, Disability, and Health (ICF)
• Rehabilitation 2023
• Rehabilitation Matters

References