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[edit | edit source]

If we consider the definition of 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”, then rehabilitation is in effect rehabilitation is 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.[1] Most individuals participating in rehabilitation require 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 interventions that allow the individual to optimise their function.[1] 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 etc rehabilitation process.

Outcome Orientated[edit | edit source]

Goal setting in rehabilitation forms the basis for selection of rehabilitation interventions which can include goals related to mobility, self-care, communication, and cognition and on more specific activities related to play, education, work, employment, socialisation, and quality of life. Different rehabilitation settings may vary in their capacities to provide specific intensities of therapies and rehabilitation itself may vary in its intensity, generally measured by the frequency and duration of individual interventions or treatment sessions. Selection of rehabilitation interventions and intensity of rehabilitations should always be based on the individual patients needs which should include their tolerance of therapeutic activities and more importantly should be generally outcome oriented, in that rehabilitation goals are developed to achieve a specific outcome, which broadly are based on five 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

Classification of Interventions[edit | edit source]

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.[2] 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]
  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).[2]
  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.[2]
    • 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.

Motivation and Adherence[edit | edit source]

Success of most, if not all, rehabilitation interventions is entirely dependent on the commitment and engagement of the people receiving the service. For example; assentive technology or strength training are irrelevant if the person does not want to use the device or undertake exercises. Therefore, rehabilitation requires some level of patient motivation and adherence to be effective.[3] Motivation in physical rehabilitation has been classified into three broad groups based on ;

  1. Patient motivation as an internal personality trait;
    • Clinicians might consider patients as coming to rehabilitation with a fixed degree of internal motivation, ranging from very high to very low. As such those with low motivation tend to be viewed as being less suitable for rehabilitation, while those with high motivation viewed more as ideal candidates for rehabilitation, and consequentially spend more time with them. [4]
    • Where patient motivation is viewed primarily as a product of internal personality traits, clinicians tend to view motivation as something that they cannot influence to any great extent. Research has shown that clinicians treat patients differently based on how motivated or unmotivated they appeared, with a preference to interact more with those patients appeared to be highly motivated and give less encouragement to those who appear to have low motivation.[5]
  2. Patient motivation as a behavioural response to social and environmental factors, and
    • In this instance clinicians and the health service as a whole can be viewed as part of the patient’s social world, and therefore can be viewed as directly influencing their level of motivation to engage in rehabilitation activities.
    • Thus the use of goal setting then may directly influence patient motivation through;
      • becoming more aware of making tangible progress towards a goal or when a goal is achieved, thus patients are more motivated and tend to try harder with future rehabilitation activities after attaining or making progress towards a goal.[5][6] Likewise this can also work in the reverse, in that not making progress or achieving a goal may make the patient despondent and demotivated, and less likely to engage in further rehabilitation. "Any goals or aims that are identified must be realistic and achievable, as setting unrealistic goals is doomed to end in failure, causing further reinforcement of the sense of hopelessness" [7], although there is limited research available to support this.
      • becoming more motivated for rehabilitation when the goals of therapy are personally relevant. [5] [8][9] The more personally meaningful a rehabilitation goal is to a patient, the more likely to participate in activities that appear to lead towards it. As such clinicians need to first identify the patient’s ‘life goals’ or 'overall goals' to ensure that the goals set by the rehabilitation team are explicitly aligned with these.[8]
      • just having a goal, which can directly influence a person’s level of effort, persistence and attention to therapeutic tasks, contributing to their self-regulation during rehabilitation. Effectvely people strive towards goals and just having the goals creates a point of focus for work. Basically just having the goal can exert an influence on an individuals behaviour before the goal is even achieved (or achievable). Evidence even suggests that difficult goals produce higher levels of effort and performance when compared with non-specific or specific, easy goals.[10]
  3. Patient motivation as an interaction between both internal personality traits and social/environmental factors.
    • In reality in day to day life, motivation and adherence to rehabilitation, is certainly more complex than just educating patients or providing them with more information about what they should or should not be doing and will always incorporate both internal personality traits and social/environmental factors. Taking the time to find out what underlies peoples’ motivation and their expectations of treatment can be very informative when planning the right rehabilitation intervention with the patient. As such its is vital that as clinicians we need to gain an understanding of the patients beliefs about the cause of their condition and their expectations of recovery, and if need be helping them towards a more appropriate match, is a crucial part of the rehabilitation planning process. [2]

Selection of Interventions[edit | edit source]

The Medical Research Council (MRC) [11] has published guidance on for research related to development, evaluation, and implementation of complex interventions to improve health, which 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 to choose appropriate methods within research, and research funders to understand the constraints on evaluation design, the first four questions are also applicable to service managers and rehabilitation professionals to guide their selection of interventions. [11]

  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, but is also relevant to clinicians in their day to day practice. When considering which interventions to use it is key that we consider the rehabilitation goals and what it is we are trying to achieve with our intervention when selecting what we are doing.
  2. Does your intervention have a coherent theoretical basis which has been used to develop the intervention?
    • Evidence based practice (EBP) is 'the integration of best research evidence with clinical expertise and patient values'[12] which when applied by practitioners will ultimately lead to improved patient outcome. 

The physical therapy profession recognizes the use of evidence-based practice (EBP) as central to providing high-quality care and decreasing unwarranted variation in practice. EBP includes the integration of best available research, clinical expertise, and patient values and circumstances related to patient and client management, practice management, and health policy decision-making. Since its implementation, there have been major advances in the quality of healthcare that is delivered, as well as patient outcomes.[13]

Although evidence-based practice encompasses more than just applying the best available evidence, many of the concerns and barriers to using EBP revolve around finding and applying research.[14] A qualitative study from 20201 looked at perceived barriers to evidence-based practice among student physiotherapists.[3] Identified barriers were: insufficient time; lack of understanding of statistical analysis; insufficient research skills; insufficient formal training; inadequate access to paid articles; an inability to critically analyse articles, and a lack of infrastructure facilities.[3]

  1. Can you describe the intervention fully, so that it can be implemented properly for the purposes of your evaluation, and replicated by others?
  2. Does the existing evidence suggest that it is likely to be effective or cost effective?
  3. Can it be implemented in a research setting, and is it likely to be widely implementable if the results are favourable?

Intervention Packages[edit | edit source]

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. [3]

ICF Intervention Table[edit | edit source]

The ICF Intervention Table can facilitate the coordination of interventions, roles and resources within a multidisciplinary team. It provides a comprehensive overview of all the intervention targets, as represented by ICF categories, the interventions themselves and the corresponding rehabilitation professional(s) who may be assigned to address each intervention target. It also shows the initial ICF qualifier rating of the intervention targets, the goal value i.e. the ICF qualifier expected to be achieved after intervention, and the end or final value i.e. the ICF qualifier rating at a second assessment or evaluation.

Essential Package of Interventions[edit | edit source]

The essential package of interventions, based on both the International Classification of Functioning, Disability, and Health [14] and the International Classification of Health Interventions [15] 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.[3] 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 . [3]

Figure.1 Essential Package Musculoskeletal & Cardiorespiratory
Figure.2 Essential Package Neurological and Assistive Devices
Figure.3 Essential Package Cross-Cutting Areas

Package of Rehabilitation Interventions[edit | edit source]

Currently the World Health Organisation are developing a new Package of Rehabilitation Interventions (PRI) resource, through a 6 step collaborative approach with rehabilitation experts and consumers from all world regions involved through each part of the process including:

  1. Selection of health conditions (for which rehabilitation interventions will be included in the PRI) based on prevalences, related levels of disability, and expert opinion;
  2. Identification of rehabilitation interventions and related evidence for the selected health conditions from Clinical Practice Guidelines and Cochrane Reviews;
  3. Expert agreement on the inclusion of rehabilitation interventions in the PRI;
  4. Description of resources required for the provision of selected interventions;
  5. Peer review process, and
  6. Production of an open source web-based tool. Rehabilitation experts and consumers from all world regions will collaborate in the different steps.


The final resource will be an open access and contain evidence-based rehabilitation interventions that will facilitate the integration of rehabilitation interventions across all service delivery platforms and also cater for different target audiences including; Ministries of Health will be able to plan the integration of rehabilitation interventions in their national health services; researchers will be able to identify rehabilitation research gaps; Academics will be able to develop curricula for the training of rehabilitation professionals; and Service providers will be able to plan and implement specific rehabilitation interventions in their rehabilitation programmes.

Summary[edit | edit source]

Rehabilitation interventions should always be considered multidimensional, interactive, experiential, comprehensive and as rehabilitation professionals we should always be flexible. In order to ensure a person-centred approach, rehabilitation intervention selection and prioritisation should be developed from the patient assessment and goal-setting processes with an evidence-based approach always considered in the design of any rehabilitation plan. Given that rehabilitation needs are very individualised rehabilitation professionals need to be open to exploring new avenues for intervention and seek creative solutions to problems with activity limitation and participation restrictions, which may involve interventions to address impairments of body structure and function, but equally may involve interventions to address environmental barriers to function or even to address personal factors that may interfere with patients achieving their life goals. [2][14]

Resources[edit | edit source]

World Health Organisation Package of Rehabilitation Interventions

References [edit | edit source]

  1. ↑ 1.0 1.1 World Health Organization. World Report on Disability 2011. Geneva: World Health Organization, 2011. Rehabilitation.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Levack, W and Dean, SG, Chapter 4 Processes in Rehabilitation. In: Interprofessional Rehabilitation: A Person-Centred Approach, First Edition. Edited by Sarah G. Dean, Richard J. Siegert and William J. Taylor. John Wiley, 2012. p97-103
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Nair SP, Panhale VP, Nair N. Perceived barriers to evidence-based practice among Physiotherapy students. J Edu Health Promot 2021;10:17. Cite error: Invalid <ref> tag; name ":1" defined multiple times with different content
  4. ↑ Maclean, N. and Pound, P. (2000). A critical review of the concept of patient motivation in the literature on physical rehabilitation. Social Science and Medicine, 50(4), 495–506.
  5. ↑ 5.0 5.1 5.2 Maclean, N., Pound, P., Wolfe, C. and Rudd, A. (2002). The concept of patient motivation: a qualitative analysis of stroke professionals’ attitudes. Stroke, 33(2), 444–450.
  6. ↑ Schut, H. A. and Stam, H. J. (1994). Goals in rehabilitation teamwork. Disability and Rehabilitation, 16(4), 223–226.
  7. ↑ Tripp, S. (1999). Providing psychological support. In: M. Smith (Editor). Rehabilitation in Adult Nursing Practice. Edinburgh: Churchill Livingstone, pp. 105–112.
  8. ↑ 8.0 8.1 Nair, K. P. S. (2003). Life goals: the concept and its relevance to rehabilitation. Clinical Rehabilitation, 17, 192–202.
  9. ↑ Wade, D. T. (1999). Goal planning in stroke rehabilitation: why? Topics in Stroke Rehabilitation, 6(2), 1–7.
  10. ↑ Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American psychologist. 2002 Sep;57(9):705.
  11. ↑ 11.0 11.1 Baird J, Unit ML, Petticrew M, White M. Developing and evaluating complex interventions. Swindon, UK: Medical Research Council. 2006.
  12. ↑ Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
  13. ↑ Albarqouni L, Hoffmann T, Straus S, Olsen NR, Young T, Ilic D et al. Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey. JAMA Netw Open. 2018;1(2):e180281.
  14. ↑ 14.0 14.1 14.2 American Physical Therapy Association APTA, Evidence Based Practice & Research, http://www.apta.org/EvidenceResearch/ (accessed 6 August 2019) Cite error: Invalid <ref> tag; name ":0" defined multiple times with different content
  15. ↑ WHO (World Health Organization). 2016c. International Classification of Health Interventions. Geneva: WHO. http://www.who.int/classifications​/ichi/en/.

 

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