Contents
1.1 Introduction and Definition 3 1.1.1 What is “Rehabilitation”? 3
1.1.2 Two Main Philosophies of Rehabilitation 3 1.1.3 Three Main Aims of the Rehabilitation Process 3 1.1.4 Three Main Features of Effective Rehabilitation 3 1.2 Rehabilitative Interventions 4
1.2.1 Difference Between Medical Intervention and Rehabilitative Intervention 4
1.2.2 Main Types of Rehabilitative Interventions 4 1.2.2.1 Internal Interventions 4
1.2.2.2 External Interventions 5
1.2.2.3 Interventions That Have Positive Effects Indirectly on the Main Impairment 5
1.3 Role of Social Context 5
1.3.1 Importance of the Role of Social Context 5 1.3.2 Evidence in Support of the Social Context 5 1.4 Multi-Disciplinary Rehabilitation Team 6 1.4.1 Formation of a Rehabilitative Team 6 1.4.2 Key Concept 6
1.4.3 Functions and Expectations of the Multi-Disciplinary Team 6 1.5 Proper and Smooth Execution of Proposed Internal and External
Interventions 6
1.5.1 Important Steps to Ensure Proper Execution of Planned Interventions 6
1.5.2 Key Concept 7
1.6 The Importance and Process of Goal Setting 7 1.6.1 Definition 7
1.6.2 Advantages of Goal Setting 7
1.6.3 Steps That May Improve the Positive Effects of Goal Setting 8 1.6.4 Outcome Measure to Assess Our Goal-Sharing Effort 8 1.7 Principles of Assessment 8
1.7.1 Introduction 8
1.7.2 Essentials of Assessment 8 1.7.3 Key to Success 8
1.8 Use of Models of Illness 9
The Rehabilitation Process, ICIDH vs ICF
1
1.8.1 Which Model of Illness? 9
1.8.2 Ways to Overcome Difficult Problems Faced by the Rehabilitation Team 9
1.9 World Health Organisation’s ICIDH vs ICF 9 1.9.1 ICIDH 9
1.9.2 Criticism of the ICIDH 9
1.9.3 Summarising the Key Drawbacks of ICIDH 10 1.9.4 Revision of ICIDH 10
1.9.5 Revision of ICIDH to ICF 11 1.9.6 ICF 11
1.9.7 Aim of ICF 11
1.9.7.1 What Is Included Under “Functioning and Disability”? 11 1.9.7.2 What Is Included Under “Contextual Factors”? 11 1.9.8 Disadvantages of ICF 11
1.9.9 Canadian Occupational Performance Measure 12 1.9.9.1 COPM Categories 12
1.9.9.2 COPM Scaling System 13
1.9.9.3 Reason for Author’s Preference for COPM over ICF 13 1.9.9.4 Useful Adjunct to COPM in Patient’s Assessment 1:
“Goal Attainment Scaling” 13
1.9.9.5 Useful Adjunct to COPM in Patient’s Assessment 2:
Functional Independence Measure 14 1.9.9.6 Preference for FIM over BI 14
1.10 Viewpoints and Surveys on “Disabilities” 14 1.10.1 Definition of Impairment 14
1.10.2 Definition of Disability 14 1.10.3 Definition of Handicap 15
1.10.4 Evidence That Disability is Frequently Missed by Practitioners 15 1.10.5 Viewpoint of Health-Workers on “Disability”:
(Room for Improvement) 15
1.10.6 Better Detection of “Disabilities” by a Multi-Disciplinary Team 15 1.11 Community Rehabilitation 15
1.11.1 Introduction 15
1.11.2 Classification of Community Rehabilitative Services 16 1.11.3 Components of Community Rehabilitation Services 16
1.11.4 Relationship Between Community Services and the Rehabilitation Team 16
1.11.5 Key Concept 16 1.11.6 Concluding Remarks 16 General Bibliography 16
Selected Bibliography of Journal Articles 17
1.1 Introduction and Definition
1.1.1 What is “Rehabilitation”?
n Rehabilitation is a problem-solving and educational process aimed at reducing the disability experienced by someone (with physical impair- ment) as a result of a disease, but always within the limitations im- posed by available resources and by the underlying disease (Wade, 1992)
n The process normally involves the following key elements viz. assess- ment, goal setting, intervention, and quality control or evaluation 1.1.2 Two Main Philosophies of Rehabilitation
n Rehabilitation is a way of thinking, not a way of doing (Wade, Clin Rehabil 2002)
n The special unique feature of a rehabilitation service is that it thinks about the patient and his problems; not simply that it does something to our patient. The service should focus on trying to help each pa- tient achieve his own goals, thinking how each obstacle can be over- come (Wade)
1.1.3 Three Main Aims of the Rehabilitation Process
n Maximise the participation of the patient in his/her social setting
n Minimise our patient’s pain and distress
n Minimise the distress of and stress on the patient’s family and/or his care-takers
1.1.4 Three Main Features of Effective Rehabilitation
n Co-ordinated multidisciplinary teamwork
n Involvement of the patient and the family
n Members with different expertise with an interest in disability man- agement
n Recognises the importance of contextural factors, i.e. personal factors, physical factors, and social factors (such as those set out in the ICF of the WHO)
a 1.1 Introduction and Definition 3
1.2 Rehabilitative Interventions
1.2.1 Difference Between Medical Intervention and Rehabilitative Intervention
n Medical intervention: interventions aimed at reversing or stopping the underlying disease process
n Rehabilitative intervention: any intervention that reverses, prevents worsening of, or alleviates an impairment and attempts to reduce dis- ability or distress will all be considered part of rehabilitation
1.2.2 Main Types of Rehabilitative Interventions
n Internal interventions
n External interventions
n Interventions that have a positive effect on another impairment, which, if improved, can aid the main impairment (e.g. improvement of cardio-pulmonary fitness)
1.2.2.1 Internal Interventions
n Agents that increase function
n Surgery to improve structure
n Patient behaviour and thinking (e.g. biofeedbacks, cognitive behav- ioural interventions by psychologists, etc.)
1.2.2.1.1 Agents That Increase Function
n An example is the use of botulinium toxin in an attempt to improve function in selected patients with cerebral palsy (CP)
1.2.2.1.2 Surgical Procedures to Improve Function
n Example: surgery (usually at multiple levels) to tackle a crouching gait in CP, this surgery will not reverse the underlying disease process of CP 1.2.2.1.3 Intervention to Change Patient’s Behaviour and Thinking
n Example of changing the patient’s behaviour is the use of the cogni- tive behavioural approach in, say, the management of chronic lower back pain (see Chap. 16)
n Changing the way the patient thinks was found to be important in various studies on tackling difficult clinical problems. Examples of the use of this strategy:
– In patients with chronic pain (Arnstein et al., Pain 1999)
– In patients with knee osteoarthritis (Rejeski et al., Arthritis Care Res 1998)
1.2.2.2 External Interventions
n Equipment to increase function (e.g. shockwave, neuromuscular elec- trical stimulation, wheelchair, aids to activities of daily life (ADL), walkers – see Chaps. 2 and 6)
n Vocational training (see Chap. 17)
n Equipment to replace or support disordered body structure (see Chap. 10)
n Arranging carers for the patient
n Environmental modifications (be it at home, or in society as a whole, e.g. proper lift access – see Chap. 10)
n Social integration (social worker, social services, voluntary agencies, peer groups, etc.) + opportunities (e.g. proper accommodation, trans- port and job opportunities, and proper respect from members of so- ciety)
1.2.2.3 Interventions That Have Positive Effects Indirectly on the Main Impairment
n Example: a patient was sent to you for rehabilitation after fractured hip surgery – identification and treatment of chronic Dupuytren’s contracture of fingers hindering hand function may improve upper limb usage of walking aids.
1.3 Role of Social Context
1.3.1 Importance of the Role of Social Context
n There is now increasing evidence that cultural attitudes and expecta- tions can be changed to reduce the burden of disability
n Thus, the response of an individual does not depend only on personal context (i.e. his beliefs), but also on social context (i.e. more wide- spread cultural expectations)
1.3.2 Evidence in Support of the Social Context
n Recent evidence, such as an important study on chronic back pain, which focuses on changing the social context, can reduce disability as mea- sured by sick leave or claims of disability (Buchbinder et al., BMJ 2001)
a 1.3 Role of Social Context 5
1.4 Forming a Multidisciplinary Rehabilitation Team
1.4.1 Formation of a Rehabilitative Team
n From the aforesaid, it will be more than obvious that proper rehabili- tation of our patients will involve a multi-disciplinary team effort
n This is particularly important in the rehabilitation of well-known complicated clinical problems in orthopaedics such as:
– Spinal cord injuries – Chronic pain – Cerebral palsy
n This book has separate sections devoted to discussing these three challenging clinical problems in rehabilitation
1.4.2 Key Concept
n An inter-disciplinary approach to rehabilitation is essential (Davis et al., Clin Rehabil 1992)
n There is no one intervention that characterises all rehabilitation 1.4.3 Functions and Expectations of the Multi-Disciplinary Team
n Work together towards common goals for the patient
n Involve and educate the patient and family
n Have relevant expertise and experience including knowledge and skills
n Can resolve most (around 90%) of the clinical problems presented to the service (Clin Rehabil 2000)
1.5 Proper and Smooth Execution of Proposed Internal and External Interventions
1.5.1 Important Steps to Ensure Proper Execution of Planned Interventions
n Setting up of a multi-disciplinary orthopaedic rehabilitative team (dis- cussed above)
n Goal setting: short- and long-term goals
n Proper assessment and identification of patient’s problems (not just orthopaedic) and with due attention to contextural factors (personal, physical and social)
n Possible use of special illness models, especially in more difficult/chal- lenging scenarios or issues (e.g. the Permission to be Sexual, Limited Information, Specific Suggestions, Intensive Therapy [PLISSIT] model)
n Assess the need for behavioural modification
n Periodic review of progress
n Liaison with community service providers for follow-up upon patient’s discharge from rehabilitative service
1.5.2 Key Concept
n Goal setting is central to the process of any systematic rehabilitative process
n Together with proper and adequate assessment, the two processes form the cornerstone of rehabilitation
n Members of the rehabilitative team must be competent in the identifi- cation and setting up of proper treatment goals
1.6 The Importance and Process of Goal Setting
1.6.1 Definition
n Goal: a future state that is desired and/or expected. It can include mat- ters involving the patient, his environment, his family or another party.
It is a generic term with no implications about timeframe or level
n Goal setting: the process of agreeing on goals, this agreement is usually between the patient and all interested parties. It may involve setting goals at various levels and in various timeframes (according to Holliday)
1.6.2 Advantages of Goal Setting
n Increase rehabilitative team collaboration
n Acts as a reminder of the patient’s interest
n May improve the long-term effectiveness of our interventions
n Shown to be associated with more behavioural change than in its ab- sence (Theodorakis et al., J Sports Rehabil 1996)
a 1.6 The Importance and Process of Goal Setting 7
1.6.3 Steps That May Improve the Positive Effects of Goal Setting
n Setting both short- and long-term goals is better than setting only long-term goals
n Goal setting is accompanied by specific interventions intended to fa- cilitate positive behaviour changes of the patient
n Significant patient participation is important for a successful outcome (Webb et al., Rehabil Psychol 1994)
1.6.4 Outcome Measure to Assess Our Goal-Sharing Effort
n The author favours the use of measures like goal attainment scaling (Stoole et al., J Am Geriatr Soc 1992)
1.7 Principles of Assessment
1.7.1 Introduction
n As mentioned, careful assessment is one of the cornerstones of the process of rehabilitation
n It should be noted that the use of outcome measures (which have been given lots of emphasis in recent years) forms only a part of the assessment process
n The myths and pitfalls in the use of outcome measures will be dis- cussed in Chap. 18
1.7.2 Essentials of Assessment
n Two key questions:
– What is the most efficient assessment algorithm for the clinical problem?
– Which specific assessment is able to give the most information with the least cost in time and effort
1.7.3 Key to Success
n There is evidence that a structured approach to assessment might lead to a better outcome than a simple clinical approach (Wikander et al., Scand J Rehab Med 1998)
n Meta-analysis studies showed that assessment is only effective (espe- cially in the elderly) if it is linked to later management (Rubenstein et al., Aging 1989)
1.8 Use of Models of Illness
1.8.1 Which Model of Illness?n Currently popularly used model of illness = ICF of the WHO
n ICF = International Classification of Functioning, Disability, and Health (see next section)
n Other models may be useful in other special circumstances 1.8.2 Ways to Overcome Difficult Problems Faced
by the Rehabilitation Team
n Explore several alternative interventions for difficult problems until the problem is overcome, but always performed in the context of the patient’s long-term goal
n Special case scenarios may resort to the use of special illness models to tackle problems, e.g. the use of models like PLISSIT when it comes to sexual issues in spinal cord injury (SCI) patients (see Chap. 12)
1.9 World Health Organisation’s ICIDH vs ICF
1.9.1 ICIDHn The ICIDH was the attempt by the WHO (World Health Organisation) to better define and classify the impact of chronic illness on the individ- ual. It attempts to classify illness in terms of diagnosis and pathological abnormalities. This concept being based on the theoretical model of dis- ablement (disease? impairment ? disability ? handicap) originally proposed by Dr. Philip Wood from UK who is a consultant of WHO
n The ICIDH presented three levels of classification: “impairment ICIDH”, “disability ICIDH”, and “handicap ICIDH”. In other words,
“I” the impairment code best describes the skeletal problem facing the patient; “D” the disability code, reveals problems in functional ac- tivity; while “H” stands for the (six) handicap codes. For details, the reader is referred to the ICIDH manual published by WHO in 1980 1.9.2 Criticism of the ICIDH
n The classification was made without due consultation with the relevant organisations like disability movement groups whose opinion should have been respected and consulted before the classification was made
n The inventors of ICIDH claimed it was not based on the medical model, but the fact that its framework is such that impairment, disability and
a 1.9 World Health Organisation’s ICIDH vs ICF 9
handicap, being all determined by a disease or disorder within the per- son, are manifestations of a direct link to the medical model
n The ICIDH’s framework stresses the role of the person within their own disability; thus, if an impairment causes a person to be unable to achieve certain tasks, they will be said to have a disability, and it has a connotation that a person will be in charge of his own disability and search for the corresponding coping mechanisms
n Little stress was put on the effect of the environment on the person’s level of disability
n The last point is important and merits clarification. For example, there are now cars designed for paraplegics, and the mere presence of the impairment – in this case paraplegia from, say, spinal cord injury – does not automatically make the person disabled. Similarly, when this patient may well return to his workplace (e.g. supposing he does paper work) provided the design of the building, including the lift and corridors, are designed with the need of persons with an impair- ment (in this case, mobility impairment) in mind
n The above serves to illustrate the extreme importance that the envi- ronment has on the individual with the impairment
n Too much stress and concentrating on the individual means that the ICIDH model does not pay enough attention to the social factors and environment. The individual is supposed to develop adequate coping strategies himself
1.9.3 Summarising the Key Drawbacks of ICIDH
n ICIDH works on the medical model of illness
n The medical model focuses on the functional capabilities of patients within the scope of their disease and not on considering what patients want to do (i.e. personal context and beliefs in the performance of his or her occupational needs), where they want to perform activities meaningful to them, and what they need to allow them to perform – in other words, importance of environmental needs and social context 1.9.4 Revision of ICIDH
n After its inception in 1980, it was revised in 1993 to take account of the role of the environment
n Subsequent revisions occurred in 1996, 1997 and 1999; then was renamed ICIDH-2, which aimed to use more neutral terminology, and attempts were made to focus more on communication among health workers
1.9.5 Revision of ICIDH to ICF
n Despite the inception of ICIDH-2, the pressure groups are of the opin- ion that WHO still defines disability medically, i.e. regarding a dis- abled person as abnormal! In view of the criticisms, the ICIDH de- vised by the WHO was revised in 2001 to become the ICF (The Inter- national Classification of Functioning, Disability and Health)
1.9.6 ICF
n The new classification is a component of health classification, as op- posed to consequences of disease
n Consists of two parts, and two components within each part
n The two parts are:
– Functioning and disability – Contextual factors
n The two components within each part can be expressed in either pos- itive or negative terms
1.9.7 Aim of ICF
n Aims to change the focus from that of the individual to focus on things that are important to the individual, like the environment and the social factors
n The second aim was to ease communication among different health care professionals
1.9.7.1 What Is Included Under “Functioning and Disability”?
n Includes aspects of body functions (domains) and activities of daily liv- ing
1.9.7.2 What Is Included Under “Contextual Factors”?
n Includes personal factors as well as environmental/societal factors 1.9.8 Disadvantages of ICF
n Does not cover disease or diagnosis
n Lacks a more positive terminology with regard to impairment and disease. We should pay due respect to patients with physical impair- ment in our society (see Fig. 1.1)
n Does not take temporal factors into account, like the patient’s stage of life and illness
a 1.9 World Health Organisation’s ICIDH vs ICF 11
n Does not acknowledge a possible difference between the person’s per- spective and the perspective of external observers
n Does not have a method of handling the question of “free-will” or freedom of choice
n Does not consider personal values and quality of life
1.9.9 Canadian Occupational Performance Measure
n This is the assessment tool much favoured by the author and will be mentioned throughout the text
n In the author’s view, the Canadian Occupational Performance Measure (COPM) is favoured mainly because it has been shown to be sensitive to temporal factors; this is important, e.g. SCI patients may change their neurological status and hence functional abilities. A brief discus- sion now follows. For details, contact the Canadian Association of Oc- cupational Therapists in Ottawa
1.9.9.1 COPM Categories
n Divided into:
– Self-care (includes personal care, functional mobility, community management, etc.)
Fig. 1.1. Signpost raised in front of one of the buildings of the Orton Foundation (Finland) for the disabled, acting as a reminder for us to pay due respect to persons with physical impairment
– Productivity (includes paid/unpaid work, household management, play/school)
– Leisure (includes quiet recreation, active recreation, socialisation) 1.9.9.2 COPM Scaling System
n The COPM has the clients prioritise the importance of reported tasks or activities into three categories as mentioned, and a scaling system used to assess the priority
n The scaling system consists of 1 = highest priority to 10 = lowest prior- ity
1.9.9.3 Reason for Author’s Preference for COPM over ICF
n It is a client-based semi-structured interview. Recall that the true phi- losophy of rehabilitation revolves around our client, not a neutral medical model
n COPM helps identify the five most important problems facing our cli- ent, thereby easing the process of goal setting between the team and client. We will recall that goal setting is another key cornerstone of the rehabilitation process
n COPM was validated as an indicator of the client’s perception of occu- pational performance and sensitive to change. Serial ratings with COPM are therefore useful (Law et al., 1998). Notice, as pointed out, that the ICF does not make much allowance for the temporal factor.
That said, the ICF can be used as a model to help the therapist to prioritise and make a more comprehensive assessment when using COPM
n Recently, COPM was also found to be adaptable to changes in pa- tient’s situations and environments as well. COPM will be used throughout the text
1.9.9.4 Useful Adjunct to COPM in Patient’s Assessment 1:
“Goal Attainment Scaling”
n Many chapters of this book deals with more complex problems in re- habilitation including rehabilitation of SCI, and CP patients
n Goal attainment scaling (GAS) is a useful tool as goal setting is im- portant in rehabilitation. This measure will be mentioned throughout this book and nicely compliments the COPM. Even in the manage- ment of amputees, it has been shown to be a reliable outcome mea-
a 1.9 World Health Organisation’s ICIDH vs ICF 13
sure relative to, say, the Locomotor Capabilities Index (LCI) (Rushton et al., Arch Phys Med Rehabil 2002)
n The GAS will be used throughout this book
1.9.9.5 Useful Adjunct to COPM in Patient’s Assessment 2:
Functional Independence Measure
n COPM is a useful tool to assess client’s priorities, but in order to as- sess client’s ADL and instrumental activities of daily living (IADL), both the functional independence measure (FIM) and Barthel’s Index (BI) can be used
n FIM is preferred to BI and used in this book
n For more complex conditions like CP, goal setting is very important and the concomitant use of COPM with goal scaling measures is use- ful
1.9.9.6 Preference for FIM over BI
n FIM is a more comprehensive measure of disability associated with physical impairment compared with BI
n It was developed by the Uniform Data System for Medical Rehabilita- tion (UDSMR) at the University of Buffalo)
n It includes assessment of communication and cognitive function, and more detailed assessment of functional mobility and self care
n Sometimes, the author uses other tools if deemed appropriate. Exam- ple: the Amputee Mobility Index is preferred to FIM for amputees
1.10 Viewpoints and Surveys Concerning “Disability”
1.10.1 Definition of Impairment
n Any loss or abnormality in the patient that is psychological, physio- logical, anatomical or functional in nature
1.10.2 Definition of Disability
n Any restriction or lack of ability to perform an activity in a manner or within the range considered normal
1.10.3 Definition of Handicap
n The way in which the disability influences the individual’s ability to fulfil a role that is normal for that individual
1.10.4 Evidence That Disability is Frequently Missed by Practitioners
n There is evidence in the literature to suggest that clinicians sometimes miss some of the disability experienced by patients
– By general practitioners: (Patrick et al., J R Coll Gen Pract 1982) – By physicians: (Calkins et al., Ann Int Med 1991)
– These two papers provide clear evidence that it is not uncommon for practitioners to miss some of the disability that patients are suffering
1.10.5 Viewpoint of Health-Workers on “Disability”:
(Room for Improvement)
n In a recent survey, it was found that health professional students held less positive attitudes than the norm. Nursing undergraduate students were at greater risk of holding negative attitudes. Specific educational experiences are needed to promote more positive attitudes among health-care workers (Clin Rehabil 2006)
1.10.6 Better Detection of “Disabilities”
by a Multi-Disciplinary Team
n Workers like Cunningham have shown in fact that detection of “Dis- abilities” among our patients are much better in the presence of a multi-disciplinary care team (Cunningham et al., Clin Rehabil 1996)
1.11 Community Rehabilitation
1.11.1 Introduction
n Rehabilitation services in the community are important, especially as a form of continuous care for the patient post-discharge. Liaison with community service providers by the multi-disciplinary care team for follow-up upon patient’s discharge from the rehabilitative service will provide a better and smoother transition
a 1.11 Community Rehabilitation 15
1.11.2 Classification of Community Rehabilitative Services
n By location of service delivery: e.g. in general hospital, rehabilitation hospital, or nursing home
n By degree and nature of specialisation
n By location of the team’s management and administrative base 1.11.3 Components of Community Rehabilitation Services
n Those specialised in specific impairments
n Those specialised in specific groups of disease (e.g. neurological dis- ability)
n Those that concern specific interventions (e.g. wheelchairs and seating)
n General supportive role
1.11.4 Relationship Between Community Services and the Rehabilitation Team
n Community rehabilitation should be an integral part of a rehabilita- tion network spanning all aspects of a patient’s needs, although there may be huge variations in management and goals amongst these dif- ferent agencies (Enderby et al., Clin Rehabil 2001)
1.11.5 Key Concept
n Community rehabilitation service should not be seen as an alternative to existing rehabilitation service. Channels for mutual referrals and liaison are most important for the continuous care of the patient 1.11.6 Concluding Remarks
n The reader should by now have an idea of what constitutes a “rehabi- litation process”
n The importance of goal setting and proper assessment will be stressed throughout the text in many chapters
General Bibliography
World Health Organization (1980) The International Classification of Impairments, Disabilities and Handicaps. World Health Organization, Geneva
World Health Organization (2001) International Classification of Functioning, Disabil- ity and Health. World Health Organization, Geneva
Harder HG (2005) Comprehensive disability management. Elsevier, London
Selected Bibliography of Journal Articles
1. De Kleijn-de Vrankijker MW (2003) The long way from the International Classifica- tion of Impairments, Disabilities and Handicaps (ICIDH) to the International Clas- sification of Functioning, Disability, and Health (ICF). Disabil Rehabil 25:561–564 2. McColl MA et al. (2000) Validity and community utility of Canadian Occupational
Performance Measure. Can J Occup Ther 67:22–30
3. Rushton PW et al. (2002) Goal attainment scaling in the rehabilitation of patients with lower-extremity amputations: a pilot study. Arch Phys Med Rehabil 83(6):771–
775
4. Wade DT (2005) Describing rehabilitation interventions. Clin Rehabil 19(8):811–818 5. Nair KP et al. (2003) Satisfaction of members of interdisciplinary rehabilitation
teams with goal planning meetings. Arch Phys Med Rehabil 84(11):1710–1713 6. Wade DT (2004) Assessment, measurement and data collection tools. Clin Rehabil
18(3):233–237
7. Wade DT (2003) Community rehabilitation, or rehabilitation in the community?
Disabil Rehabil 25(15):875–881
8. Wade DT (2002) Rehabilitation is a way of thinking, not a way of doing. Clin Reha- bil 16(6):579–581
a Selected Bibliography of Journal Articles 17
