Introduction to Basic Rehabilitation Techniques

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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 over a billion people 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 the conditions that impact their functions in daily life and would benefit from rehabilitation services, which equates to 1 in 3 individuals requiring rehabilitation services throughout the course of 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 Organisation 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 Organisation'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

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 with incorporation of techniques that allow for assessment and identification of problems in all areas of the ICF, followed by selection of interventions that address impairments in body functions and structures, activity limitations and participation restrictions, considering contextual factors both personal and environmental, that impact functioning.

Most individuals participating in rehabilitation require techniques and interventions addressing one, many or all of the components of the ICF that are contributing to reduced functioning, with the overriding goal of rehabilitation being 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 in time across the course of 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; the way in which the person’s condition affects their ability to function in their environment; as well as the individual’s identified personal goals and what it is they want to achieve from the rehabilitation process.

The comprehensive and holistic nature of the ICF make 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 more 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 and has been viewed as a critical element directed at enhancing rehabilitation outcomes. Rehabilitation interventions are only as good as the assessment on which it is based. The clinical assessment provides the information that is used 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 context of rehabilitation, but effectively encompasses collection and evaluation of patient data in order to guide 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 that should occur throughout the rehabilitation process in order 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

The Medical Research Council has published guidance on research related to the development, evaluation, and implementation of complex interventions to improve health. It recommends considering the following five key questions when developing a rehabilitation intervention, particularly in the case of complex healthcare. While the guidance was intended mostly to help researchers choose appropriate methods within research, and research funders to understand the constraints on evaluation design, the first four questions are also applicable and relevant to service managers and rehabilitation professionals to guide their selection of 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 looking at researching the impacts of an intervention, or are selecting a technique or an 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 and their rehabilitation goals should be central to what it is we are trying to achieve with our intervention when selecting what we are doing. Incorporating a patient's cultural considerations, needs, and values is a necessary skill to provide 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 decision-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 a key part of this evidence-based process with the personal scope of practice consisting 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. 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 healthcare that is delivered, as well as 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?
   • While this is particularly vital in research so that studies can be replicated, or further developed within our clinical practice as rehabilitation professionals, this is also important so that other rehabilitation professionals working with a person have a good understanding of the rehabilitation techniques and interventions being used. It is also important if a person's rehabilitation is being transferred to another member of the team so that they can evaluate and continue to provide and build on rehabilitation interventions that have been effective.
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 or 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, and as clinicians, we need to be able to weigh up the technique or intervention options available and considering both the effectiveness of the technique or intervention in assessing the patient in order to optimise both the function of the individual but also the cost implications for the technique or interventions, both for the individual (particularly where the individual is having 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