Clinical Rehabilitation 2005; 19: 811 -818

Editorial

Describing rehabilitation interventions

Rehabilitation is an effective process for reducing the morbidity and sometimes the
mortality associated with many illnesses. This statement is supported by much
evidence, but there is less evidence to support most specific actions undertaken in
rehabilitation. In part this is inevitable because there are so many interventions.
However the lack of an adequate system to classify and describe the complex
interventions that constitute rehabilitation is also a great hindrance. This is in marked
contrast to the detailed specification used in pharmacological research and
reasonable description available for some surgical interventions. This editorial puts
forward a classification system that is derived from two models relevant to
rehabilitation: the World Health Organization's International Classification of
Functioning model of illness and a model of rehabilitation described here.
Interventions may be described in terms of the situations where these actions are
applied, the immediate goals of any action, the level at which the intervention acts,
the actions involved, the knowledge and skills needed to give the treatment, any
specific equipment used, and any concomitant actions that may be necessary. In
addition the context of the interventions should be described: the underlying theory
or principles guiding actions, and the organization of the service internally, and in
relation to other related services.

Introduction ences or change, and allow generalization. Using

Rehabilitation is an astoundingly effective health
care process. Most dramatically, people would die
after spinal cord injury without rehabilitation but
they live full lives of near-normal duration. Stroke
rehabilitation is proven more scientifically to be
effective.' In both cases we are unable to describe
the specific effective rehabilitation interventions
accurately, if at all. This difficulty in characterizing
the nature of the rehabilitation process reduces its
credibility in the competitive health care market. It
also hinders research. This editorial considers how
we could describe rehabilitation.
Rehabilitation: a complex intervention
Research depends upon methods that minimize
bias, increase the likelihood of detecting differ-
2005 Edward Arnold (Publishers) Ltd
a control to minimize the effects of expectation
in patients, randomizing choice and minimizing
expectation in observers are the usual techni-
ques used. Biomedical research using these meth-
ods has greatly benefited all aspects of health
care, including rehabilitation. Most biomedical
researchers are able to give an unambigu-
ous description of most variables, especially the
(usually pharmacological) intervention underta-
ken. The difficulty in specifying the nature and
content of complex health care interventions is
now being recognized.2'3 No simple solutions have
been found.
Rehabilitation is perhaps the archetypal complex
intervention. Research into rehabilitation has
rarely specified the activities being investi-
gated, which hinders both the research itself
and the wider acceptance of any research under-
taken. Indeed it is difficult to find clear descrip-
tions of the content of rehabilitation for most
10. 1 191/026921 5505cr923ed
812 Editorial
conditions, even in textbooks. More work is The theoretical foundations of
needed to improve the vocabulary used to describe rehabilitation
rehabilitation.
There are several obstacles to overcome because
the word rehabilitation encompasses so many
activities. It includes a large number of specific
treatments. For example the huge variety of treat-
ments used in rehabilitating even a single pro-
blem, hemiplegic shoulder pain, have been well
documented.4 Despite various attempts to derive
descriptions of treatments,5'6 there is currently no
agreed vocabulary or method for describing
treatments. Furthermore, the rehabilitation pro-
cesses and interventions may be influenced by the
theoretical basis (whether based on evidence or
not) underlying the clinical approach to pro-
blems. This is another important descriptive
aspect. For example practitioners of the Bobath
approach to people with abnormal motor control
secondary to neurological disease will have a
different analytic and treatment approach to
others using (for example) the Motor Relearning
Programme. It is quite difficult to elucidate the
approach of the Bobath school of physio-
therapy,7 and it may vary over time.8 Of
course much rehabilitation practice is atheoreti-
cal, sometimes described as 'pragmatic' or
'empirical'.
Lastly, rehabilitation occurs in a context that
encompasses both the place of the activity being
studied within the organization of the service
itself (e.g., treadmill training may be studied
within a specialist multidisciplinary stroke service
or in an isolated physiotherapy service), and
the place of that service within the many other
services that may be involved with someone
who has a disabling condition.
In summary, a full description of rehabilitation
would require definition of:
* the organization of the programme, including
how it interrelates with other health and non-
health services involved with people with long-
term activity limitation; and
* the theoretical model underlying or basis of the
programme; and
* the specific actions and activities undertaken.
A theory or explanatory model is essential to
analyse any situation, to decide on actions and to
define the concepts and words used. Consequently
we need to have a logically consistent, clear model
or set of models or theories to form the founda-
tions of rehabilitation. Three models (or theore-
tical bases) are required.
The first theory needs to relate to illness and
disability, explaining how activity limitation arises
and thus what factors might be treated. The second
theory needs to relate to the process of rehabilita-
tion, explaining the process and possibly its goals,
and how it is organized. The third theory needs to
explain how behaviour is changed because all
rehabilitation, at its heart, concerns changing
behaviour.
Theories of behaviour change, which must
underpin most if not all rehabilitation treatments,
will not be considered further here despite their
central importance.
Illness models
The illness model that has been developed
by rehabilitation specialists is the model that
underlies the World Health Organization's Inter-
natlonal Classification of Functioning (WHO
ICF), which has been developed into a reason-
ably comprehensive and logically consistent
model.9"10 This model will be used here because
its validity and utility is supported by its wide-
spread and continuing use.' 1,12
As shown in Table 1, the WHO ICF model
allows a reasonable classification of the focus or
target of any intervention. Three specific features
should be noted. First free will, or patient choice is
considered a legitimate target for intervention.
This acknowledges the importance of a patient's
choice in determining activity performance, but
also suggests that, in certain circumstances at least,
it is reasonable for rehabilitation services to try to
influence this choice. Choice may be influenced by
providing information, or more systematically
through rewarding wanted behaviour and not
 Editorial 813
Table 1 A classification of rehabilitation treatment domains
Domain Comment Example
Patient
Pathology Often not reversible or curable, but reduction Interferon-beta for multiple sclerosis
or control may be important
Impairment May be reduced directly, or Botulinum toxin for local spasticity; exercise to
indirectly through
activities, or controlled increase fitness; analgesia, L-dopa for Parkinson's
disease
Activities May be taught (usually new ways of achieving Treadmill gait retraining, using an environmental
goals, or use of equipment) or practised control system, writing using nondominant hand
Participation Cannot give someone new roles, but may Suggest that a manual worker retrain to be an
suggest possible roles and should facilitate office clerk, and put in touch with appropriate
development of new roles (and possibly training course
giving up old roles)
Contexts
Choice, or free will Can be altered through giving information, Explain health advantages of work over being 'off
advice, etc. May be altered through more sick'; inform about expectation of health system.
structured behaviour modification programme Ignore unwanted behaviour but respond to wanted
(structured responses to wanted and unwanted behaviour
behaviours)
Personal Changing expectations, beliefs and attitudes, Cognitive behavioural therapy is prime example of
and agreeing goals all may help motivation therapy aimed at personal context
(i.e., willingness to participate in process)
Physical Refers to all aspects of physical environment, Provision of orthosis, prostheses, wheelchairs and
including adaptation of clothes, altered or new adapted cutlery. Also teaching carers how to
equipment, housing adaptations, and the pre- assist, structuring environment
sence of people as providers of hands-on care
or supervision
Social Altering the social context is usually a slow Altering legal framework. Changing population
process as involves changing attitudes, expectations
expectations and beliefs of those interacting
with the person
Temporal Providing a predictable structure to day, and Arranging a stable, predictable care routine
ensuring that the person has opportunities to
undertake and/or participate in activities
throughout the day may be important

rewarding unwanted behaviour (so-called 'beha-
viour modification').
Secondly it should be noted that rehabilitation
treatments will often be targeted at two (or more)
domains. For example, providing almost any
specialized piece of equipment (i.e., altering the
physical context), such as a wheelchair or walking
stick, should be accompanied by a period of
teaching and practising the relevant activity
(i.e., an intervention at the level of activity limita-
tion). It might also be accompanied by treatment
to reduce spasticity (i.e., reducing an impairment).
Lastly the temporal context of a patient refers to
the organization of time. Although rarely dis-
cussed, most people live within a reasonably stable
routine with predictable activities at predictable
times. Some people may lose much of the social
routine, for example if unemployed, and others
may need a higher than usual level of routine, for
example if markedly amnesic. Ensuring a stable,
externally maintained routine is sometimes an
important part of rehabilitation treatment.
The model of illness will not be described or
discussed any further because it is widely written
about and will be well known to most readers.
A model of the rehabilitation process
In contrast there is not yet a fully agreed or
widely used definition or model of rehabilitation.
814 Editorial
However it is essential to have one, to describe tion on those activities they need or wish to
the process. A model of the process has been undertake. A working definition of the goals of
proposed,'3 developed'4"15 and used,","2 and this rehabilitation that encompasses the global aims of
theory will be described here. In summary it health care systems in a more detailed way is as
suggests that rehabilitation is a problem-solving follows:
process just like any other problem-solving process, The goals of rehabilitation are:
with its own specific focus on activity limita-
tion and its own set of goals, namely optimi- * To optimize social participation of patient
zation of a person's social participation and - optimize social role function
well-being. - optimize social status
A working definition of rehabilitation is given as * To maximize well-being of patient
follows: - somatic and emotional;
Rehabilitation is an educational, problem-sol- - achieving satisfaction (adaptation to situa-
ving process that focuses on activity limitations tion)
and aims to opimize patient social participation * To minimize stress on and distress of relatives
and well-being, and so reduce stress on carer/ - somatic and emotional.
family.
The process of rehabilitation is a standard pro-
It is similar to many others, hopefully it cap- medicalblem-solving process, just as used in traditional
tures the central core of rehabilitation, but it or indeedpractice when making a disease diagnosis,
in
should not be taken as a unique or immutable It is a reiterative management
any in any organization.
definition. process and is shown in Figure 1.
Rehabilitation can be considered in three ways: The first stage is to identify the problems faced
by the person, and to collect sufficient information
* the process of rehabilitation; what happens? to make progress. Given that rehabilitation focuses
* the structures needed to undertake rehabilita- on reducing activity limitation, it is likely that
tion; what is needed for rehabilitation? screening for activity limitations, followed by
* the outcomes expected from rehabilitation; what collecting data from almost all other relevant
is the result? domains will be needed, with especial emphasis
on establishing the patient's goals and expecta-
The structures will follow largely from the process tions. The importance of the assessment process
and goals (expected outcomes). has been discussed.'6'17
The goals of rehabilitation cannot be derived The second stage is to set goals for the im-
from any first principles. They ultimately acquire mediate future and also for the longer term. The
validity through general use and acceptance by all generic benefits of setting goals have been well
concerned parties. However the stated goal of most established, 8 though there is less evidence sup-
health care systems and most of those funding porting goal-setting within health care and reha-
health care is to maximize a patient's well-being, or bilitation. 9 In rehabilitation, in contrast to acute
quality of life, or health. Whichever of these words medical settings, there will be more emphasis upon
is used, it is obvious that the stated goals of health establishing the patient's wishes and more empha-
care in general are global, and not restricted to any sis upon longer term goals, usually at the level
small part of the illness model. of activities or participation.
Rehabilitation is a health care activity. Legi- The third stage is to undertake the planned
timate goals of the rehabilitation process may interventions. In principle three types of interven-
therefore include optimizing social role function tion exist:
and minimizing patient and family distress. In
practice these goals will be achieved primarily * continued data collection (which is really part of
through maximizing a patient's behavioural reper- assessment),
toire; in other words by giving them the skills * providing any support needed to maintain the
and equipment needed to minimize the limita- patient's well-being, and
 Editorial 815

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816 Editorial
* giving treatments which are actions that are for maintenance of health, for review if appro-
intended to alter the natural history of priate, and for re-entry to health care and rehabi-
the situation. litation with guidance on when this is appropriate
and how it should occur.
Support and treatment may be directed at the
patient and/or their physical and social context.
Support is defined here as any intervention that
is needed simply to maintain the patient's situa- Describing rehabilitation
tion. It includes physiological support that is
usually given within an intensive care unit, and These two models should allow a description of
support in activities such as feeding and dressing. any rehabilitation procedure in a reasonably clear
Most of these interventions act on the patient, manner using a consistent vocabulary. The proce-
though some support actions such as ensuring a dure should be located within the overall process
quiet, structured and secure environment do not (i.e., assessment, or goal-setting, or intervention,
act on the patient directly. or evaluation), and should be described using three
Treatment is defined as any intervention that axes:
leads to a sustained change in the natural history
or expected course of the patient's illness. Note * Structure: What resources are needed or were
that change should be sustained after treatment
is reduced and stopped. If continuing a treatment * used? Process: What actions (activities) should be or
is necessary to maintain a situation then it were undertaken?
becomes care/support. This is important because * Outcome: What should be or was the goal of the
in general treatments involve professional staff process?
with generic knowledge and skills, whereas care
involves people, also often professional and skilled, While it would clearly be impractical to do this
who should be taught the particular skills needed in great detail on every occasion, nonetheless
to provide the specific care needed for that person this provides a framework for accurate description
but who do not have the generic level of skill and (and analysis of what has not been specified), and
knowledge. it is summarized in Table 2.
The distinction between support and treatment Before describing any specific rehabilitation
is important. Often the resources needed to main- procedure, it is important to define the specific
tain health and safety are the major cost of clinical situation that is being acted upon. In other
rehabilitation. This exaggerates the costs of reha- words, what are the characteristics of the patient or
bilitation. The care costs would be incurred any- the situation that the process is appropriate for?
way; hopefully rehabilitation should reduce them Examples include: any patient with any gait distur-
in the long term. The distinction, clear in principle, bance arising from neurological damage (e.g., for
is not always easy in practice. For example the gait analysis), any patient with recent onset
process of feeding a patient could constitute both neurological damage who is entering an inpatient
support and treatment if the patient is also rehabilitation programme (e.g., for goal-setting),
learning how to feed him or herself. any patient with unilateral spasticity affecting the
The final stage in the process is to evaluate the hand (e.g., for botulinum toxin injection).
effects of the interventions against the goals set. At It is then best to define the expected outcome,
that point the team needs to determine whether the goals of the activity; what is this process trying
there are still unresolved but resolvable problems, to achieve? Examples include: selecting patients for
in which case the cycle continues, or whether orthopaedic operations to improve gait, setting
all resolvable problems have been treated in which rehabilitation goals, and using a splint to reduce
case the active process of rehabilitation has contracture formation. In practice many proce-
finished. dures will have both immediate (proximate) goals
The process of discharge from rehabilitation and more general (distal) goals and all should
does, however, involve making plans as necessary be given.

Table 2 Describing a rehabilitation procedure
Domain Subdomains
Target situation (input) None
Goal (anticipated outcome) Proximate, immediate goal
Distal, general goal(s)
Activity (process) Direct (focus of attention)
Ancillary (not focus of attention
but required)
Resources (structure) Physical (equipment etc.)
Knowledge (of staff)
Skills (of staff)
Context Organization
Theoretical basis
Next the process (actions or activities them-
selves) should be described. The WHO ICF should
be used to categorize and describe the actions. In
practice it will frequently be necessary not only to
describe the specific action of concern, but
also ancillary actions not specifically being studied
or described but necessary for success. This
refers especially to associated treatments such as
therapy given after botulinum toxin injection,
training given after providing special equipment,
and opportunities being provided for social com-
munication after giving specific speech therapy.
The description should always encompass both
the nature of the actions and also the amount
or quantity.
Lastly the structures needed to undertake the
process should be defined. What equipment (if
any) is needed? What level of knowledge and skills
do the health care personnel need?
In addition, to allow others to interpret and
use the findings, it is helpful to set the speci-
fic rehabilitation service where the project was
undertaken in context. How is it organized intern-
ally? How does it relate to other services?
How is it funded? What constraints are there
on rehabilitation?
Editorial 817
Comments
Describes the clinical and other features that lead
patients into the procedure. It is the selection criterion.
The procedure will have a purpose, which should be
given. For intervention the distinction between treatment
and support should be made
The description will be of a series of actions, which may
also include giving patient specific resources (e.g., drugs,
equipment) which should be specified. Most procedures
occur within the context of an overall rehabilitation
programme, and it is essential to define any other
procedures that are required for the success of the
direct action
This covers the local context of the procedure, including
some indication of the experience of the treating person
and any ancillary equipment needed (but not necessarily
given to the patient)
Organization covers the health care setting; how does
this service relate to other health and nonhealth services.
It might also include the internal organization of the
service. It is also important to specify the theoretical
basis underlying activities, if there are any
All description should be given in simple terms,
avoiding all jargon especially jargon specific to the
profession involved.
Conclusion
This theoretically driven method for describing
rehabilitation in more detail is no more than that -
an unproven idea. It has not yet been put to
the test. The only support available is that a similar
framework was used when framing recommen-
dations for the UK National Guideline on the
Management of Multiple Sclerosis in Primary and
Secondary Care,'2 and it seemed to work then.
Derick T Wade
Editor-in-Chief
Acknowledgements
I am grateful to Professor Maria Gabriella
Ceravolo and the Italian Society for Neurological
Rehabilitation for stimulating me to consider this
topic (by asking me to speak about it) and for
providing some time to consider it.
818 Editorial
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