Interprofessional Rehabilitation E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 435

Veröffentlichungsjahr: 2012

Beschreibung

Interprofessional Rehabilitation: a Person-Centred Approach is a concise and readable introduction to the principles and practice of a person-centred interprofessional approach to rehabilitation, based upon a firm scientific evidence base.

Written by a multi-contributor team of specialists in physiotherapy, occupational therapy, nursing, psychology and rehabilitation medicine, this text draws together common themes that cut across the different professional groups and the spectrum of health conditions requiring rehabilitation, and sets out a model of practice that is tailored to the specific needs of the client. Showing interprofessionalism at work in a range of clinical contexts, the book argues that effective rehabilitation is best conducted by well-integrated teams of specialists working in an interdisciplinary way, with the client or patient actively involved in all stages of the process.

This book will be essential reading for students preparing for practice in an increasingly interprofessional environment, and will be of interest to any health care practitioner keen to understand how an integrated approach to rehabilitation can benefit their clients.

Leseprobe

Contents

About the editors

About the contributors

Foreword: by Professor Gerold Stucki

Preface

Acknowledgements

Chapter 1 Introduction

1.1 What is rehabilitation?

1.2 Setting boundaries – or what we don’t mean by rehabilitation

1.3 Some definitions of rehabilitation

1.4 Some other issues in defining rehabilitation

1.5 The core themes

1.6 A word about terminology

1.7 Summary

Chapter 2 A rehabilitation framework: the International Classification of Functioning, Disability and Health

2.1 There is a need for a common language of functioning

2.2 The ICF is both a model and a classification system

2.3 The origins of the ICF

2.4 Using the ICF in practice – ICF core sets, rehabilitation cycle and ICF tools

2.5 Can the ICF be used to measure functioning – both the ‘what’ and the ‘how’? Controversies – to measure or to classify that is the question

2.6 Controversies – classification of ‘participation restrictions’ versus ‘activity limitations’

2.7 Controversies – is the ICF a framework for understanding ‘QoL’?

2.8 Future developments of the ICF

Chapter 3 An interprofessional approach to rehabilitation

3.1 Introduction and setting the scene

3.2 Terminology and interprofessional working within rehabilitation

3.3 Characteristics of good teamwork

3.4 Team membership and roles

3.5 Processes of teamwork

3.6 The role of interprofessional education in rehabilitation

3.7 Collaborative rehabilitation research

3.8 The future for interprofessional rehabilitation teams

3.9 Conclusion

Chapter 4 Processes in rehabilitation

4.1 Introduction

4.2 Assessment

4.3 Goal planning

4.4 Interventions

4.5 Evaluation

4.6 Discharge planning and transitions from hospital to community

4.7 Conclusion

Chapter 5 Outcome measurement in rehabilitation

5.1 Introduction

5.2 Psychometrics – a primer

5.3 Applying outcome measures in clinical practice

5.4 Conclusion

Chapter 6 The person in context

6.1 Introduction

6.2 Who are the stakeholders in rehabilitation?

6.3 Key terms

6.4 The lived experience of acquired disability

6.5 Rehabilitation as a personal journey of reconstruction or transformation of the self

6.6 Understanding rehabilitation as ‘work’ and the role of participation

6.7 Clinical services guiding and supporting personal rehabilitation journeys

6.8 Placing the person in their family context and involving families in rehabilitation

6.9 Ideas for making clinical rehabilitation processes and practices person-centred

6.10 Can we do person-centred rehabilitation?

Chapter 7 Conclusion: rethinking rehabilitation

7.1 Introduction

7.2 The ICF as a theoretical framework and language for rehabilitation

7.3 Interprofessional teamwork in rehabilitation

7.4 Processes in rehabilitation: goal setting and its mediators

7.5 Outcome measurement to evaluate rehabilitation and show it makes a difference

7.6 The importance of the individual person in their context and how to do person-centred rehabilitation

7.7 Using the ICF as a way to map interprofessional rehabilitation

7.8 Revisiting the definition of rehabilitation

7.9 Limitations related to the scope of this textbook

7.10 Future directions of interprofessional rehabilitation

7.11 Conclusion

Index

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Library of Congress Cataloging-in-Publication Data

Interprofessional rehabilitation : a person-centred approach / edited by Sarah G. Dean, Richard J. Siegert,William J. Taylor.p. ; cm.Includes bibliographical references and index.

ISBN 978-0-470-65596-2 (pbk. : alk. paper)I. Dean, Sarah G. II. Siegert, Richard J. III. Taylor, William J., 1964–[DNLM: 1. Rehabilitation–psychology. 2. Evidence-Based Medicine. 3. Patient Care Team.4. Treatment Outcome. WB 320]616.86′03–dc23

2012015864

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover design by Meaden CreativeCover image © iStock

About the editors

Sarah G. Dean, PhD, CPsychol, MSc, MCSP, Grad Dip Phys, BSc Jt Hons, Senior Lecturer in Health Services Research, part of the Peninsula Collaboration for Leadership in Applied Health Research and Care (PenCLAHRC) based at the University of Exeter Medical School, United Kingdom. Sarah is a chartered ­physiotherapist who trained at Guy’s Hospital London, after completing her first degree in psychology and physical education at the University of Birmingham, United Kingdom. She worked clinically in both the NHS and private sector, ­specializing in musculoskeletal rehabilitation, particularly exercise therapy for sports injuries and cardiac rehabilitation. During this time she was competing as an athlete representing Great Britain in the 400 m hurdles. From 1995 she lectured in ­physiotherapy for nearly nine years at the University of Southampton and completed her PhD in health psychology in 2003. Her PhD investigated the use of illness ­perceptions for facilitating adherence to physiotherapy exercises for people with low back pain. In 2004 Sarah went to work in New Zealand as a senior lecturer in rehabilitation at the University of Otago, Wellington as part of the interprofessional Rehabilitation Teaching and Research Unit, she became a chartered psychologist in 2006. In 2009 Sarah returned to the United Kingdom to take up her current post. Sarah’s research interests include applying psychology to rehabilitation medicine, such as goal setting and facilitating adherence to exercise therapy, for a number of different chronic conditions including stroke, low back pain and urinary incontinence. She uses qualitative and mixed methods for her research. Sarah teaches undergraduate medical students and supervises postgraduate students.Richard J. Siegert, BSc, MSocSci, PGDipPsych(Clin), PhD, Professor of Psychology and Rehabilitation, School of Rehabilitation and Occupation Studies and School of Public Health and Psychosocial Studies, AUT University, Auckland, New Zealand. Richard trained as a clinical psychologist in Wellington, New Zealand where he worked in diverse settings including mental health, forensic psychology, private practice and neurology. His PhD examined the relationship between social support and stress among unemployed people and resulted in six publications in international journals. Richard taught psychology at Victoria University of Wellington, specializing in clinical neuropsychology, before joining the Rehabilitation Teaching and Research Unit of the University of Otago in Wellington. Since then his teaching and research has focused on rehabilitation for neurological conditions. In 2007 he joined the staff of the Department of Palliative Care, Policy and Rehabilitation at King’s College London where he was a Reader in Rehabilitation. In March 2012 he took up his current post. He is the author of 80 academic journal articles and six book ­chapters. Current research interests include psychometrics applied to neurological rehabilitation and palliative care, goal setting in rehabilitation and measuring community ­integration among people with complex disability.William J. Taylor, PhD, MBChB, FAFRM, FRACP, Associate Professor in Rehabili­tation Medicine, Rehabilitation Teaching and Research Unit, University of Otago Wellington and Consultant Rheumatologist and Rehabilitation Physician, Hutt Valley District Health Board, Wellington, New Zealand. Will trained in rheumatology and rehabilitation medicine, obtaining vocational registration in these areas in 1998. He continues to practise clinical medicine in Wellington, New Zealand. His PhD, partly based in Leeds United Kingdom, led to the widespread adoption of new classification criteria for the diagnosis of psoriatic arthritis. He now leads the Rehabilitation Teaching and Research Unit of the University of Otago Wellington, which is responsible for providing an interdisciplinary and distance-taught programme of studies in rehabilitation to postgraduate health professionals from diverse backgrounds. Will supervises research students and is actively involved in research in a variety of fields including vocational rehabilitation, goal setting, outcome measurement and clinical trial methodology (especially in gout and psoriatic arthritis). He works in collaboration with a number of local and overseas researchers including AUT University, OMERACT (Outcome Measures in Rheumatology Clinical Trials), GRAPPA (Group for Research and Assessment in Psoriasis and Psoriatic Arthritis) and the International Classification of Functioning, Disability and Health Research Centre. He has a particular interest in instrumentation, psychometrics and clinical epidemiology. A current research interest concerns response criteria following treatment for gout and classification criteria for gout. Will was a member of the New Zealand National Health Committee from 2007 to 2010, and is a member of the academic subcommittee of the ARFM (Australasian Faculty of Rehabilitation Medicine) and the continuing professional development subcommittee of the ARFM. He is the immediate past president of the New Zealand Rehabilitation Association.

About the contributors

Jo Adams, PhD, MSc, Dip COT, MBAOT, Senior Lecturer and Professional Lead for Occupational Therapy, Faculty of Health Sciences, University of Southampton United Kingdom. Jo is an occupational therapist who completed her clinical training at Cardiff. She has worked as an occupational therapist in the NHS, Social Services, higher education and within the voluntary sector in the United Kingdom, North America, Bangladesh and Uganda. Jo has a specialist interest in musculoskeletal rehabilitation and a particular focus on maximizing individuals’ self-management skills and strategies across all groups of patients and clients. Her funded research projects involve close clinical collaboration with educationalists, rheumatologists, surgeons, engineers, nurses and therapists. Much of this collaborative work results in randomized controlled trials examining the clinical effectiveness of routine NHS clinical and educational interventions in ­rheumatology. Jo has for the past 16 years also been a keen and enthusiastic educator for undergraduate and postgraduate healthcare students striving to ensure that contemporary research and evidence-based practice is quickly embedded into healthcare education.Claire Ballinger, PhD MSc Dip COT, Deputy Director/Senior Qualitative Health Research Fellow, National Institute for Health Research (NIHR) Research Design Service South Central, University of Southampton, United Kingdom. Claire qualified as an occupational therapist from Dorset House School of Occupational Therapy, Oxford, and worked with both older people, and people with learning disabilities for 8 years. She registered as a full-time student on the MSc in Rehabilitation Studies at the University of Southampton in 1989, and on graduating in 1991, took up her first academic post as a Lecturer in Rehabilitation at Southampton, evaluating disability equipment in the new Southampton Disability Equipment Assessment Centre. Claire joined the Southampton School of Occupational Therapy and Physiotherapy in 1994, and in 1996 was awarded a full time PhD research studentship by the Department of Health. After gaining her PhD in 2000, Claire became joint Head of Postgraduate Education in the School of Health Professions and Rehabilitation Sciences at Southampton before accepting a post as a Reader in Occupational Therapy at London South Bank University. She became a Professor of Occupational Therapy at Glasgow Caledonian University, before returning to Southampton to her current post in 2009. Claire has a Visiting Chair at London South Bank University, and has recently reached the end of her term of office as Chair of the College of Occupational Therapists’ Specialist Section – Older People. Her research interests include the design and evaluation of complex health interventions for older people, notably falls prevention, and she has particular expertise in qualitative research approaches, with a growing interest in ­randomized controlled trial design. Within the Research Design Service South Central, Claire has a strategic remit for patient and public involvement (PPI).Szilvia Geyh, PhD, MPH, Dipl-Psych, Affiliated Teaching Fellow, Department of Health Sciences and Health Policy of the University of Lucerne, Switzerland. Szilvia is group leader at Swiss Paraplegic Research (SPF) and coordinates a research ­programme focusing on psychosocial and personal factors in spinal cord injury. Her teaching fellow position includes supporting PhD as well as master students. Szilvia holds a degree in psychology from the Catholic University of Eichstätt, a postgraduate master in public health and epidemiology as well as a PhD from the medical ­faculty of the Ludwig-Maximilian University (LMU) in Munich. Between 2001 and 2007 she worked as a research scientist in projects for the development and validation of the International Classification of Functioning, Disability, and Health (ICF) core sets for chronic health conditions at the Institute for Health and Rehabilitation Sciences of the LMU in collaboration with the World Health Organization (WHO). Her research interests circle around the comprehensive understanding of the lived experience of people with disabilities based on a biopsychosocial framework. Her work especially focuses on protective factors and psychosocial resources. She is also concerned with the conceptualization of the personal factors within WHO’s ICF framework. Szilvia has a special interest in the problems of defining and measuring quality of life in people with disabilities, in person-centred rehabilitation and positive psychology. She has acted as a ICF trainer in national and international onsite, ­university and research workshops. She is specialized in the application of the ICF in neurological conditions, with a main focus on stroke and spinal cord injury. In ­addition, she has methodological expertise in Rasch analysis techniques for the ­evaluation and refinement of assessment instruments, and in conducting systematic literature reviews.William Levack, PhD, MhealSc(Rehabilitation), BPhty, Associate Dean, Research and Postgraduate Studies for the University of Otago Wellington and Senior Lecturer in Rehabilitation for the Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, New Zealand. William is a New Zealand registered physiotherapist who trained at the University of Otago. He began his clinical career working in New Zealand’s public health system, primarily in services ­providing treatment and rehabilitation for aged-related neurological and respiratory conditions, before moving to help establish a new branch of a private residential rehabilitation service for people with acquired brain injury in the community. Afterwards, William returned to the public health system to work as the Physiotherapy Team Leader for Wellington Public Hospital, managing a team of 30 physiotherapists and support staff. In 2003, William was employed as a Lecturer at the University of Otago, ­teaching interdisciplinary, postgraduate courses in rehabilitation by distance, and in 2008 he completed his PhD. William’s research interests include goal theory, patient engagement in rehabilitation and interprofessional rehabilitation processes. His ­current research projects includes work on the development of a clinical measure of loss and reconstruction of self-identity after traumatic brain injury, qualitative research into the barriers and facilitators of access to evidence-based rehabilitation, and the use of kinetic video games as a form of therapeutic exercise for people with chronic respiratory disease.Julie Pryor, RN, RM, BA, GradCertRemoteHlthPrac, MN, PhD, FRCNA, Director of the Rehabilitation Nursing Research & Development Unit, Royal Rehabilitation Centre, Sydney, Australia. Julie is also an Associate Professor at Flinders University, where she contributes to Australia’s only postgraduate multidisciplinary clinical rehabilitation programmes. She is a registered nurse with a passionate interest in rehabilitation. Since the mid-1980s Julie has held a variety of clinical, management, education and research positions in rehabilitation. Since the mid-1990s she has researched and published widely about rehabilitation, in particular nursing’s role in rehabilitation, and provided consultancy advice to about 20 rehabilitation service providers across Australia and New Zealand. Julie’s current areas of interest are ­making the person central to all the processes of clinical rehabilitation service ­delivery and the integration of clinical and community-based rehabilitation. She predominantly uses qualitative research methods and frequently works within a practice development framework.

Foreword

by Professor Gerold Stucki

Responding to a call by the World Health Assembly (2005) resolution on disability, including prevention, management and rehabilitation, the World Report on Disability (WRD) (World Health Organization (WHO), The World Bank, 2011) was launched at the United Nations headquarters in New York on 9 June 2011. By recognizing the Convention on the Rights of Persons with Disabilities (United Nations General Assembly, 2006) as its moral compass and the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) as its conceptual framework, the WRD provides rehabilitation practitioners and researchers worldwide with an influential global health policy reference.

The WRD defines 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 environment’ (2011, p. 308). This definition is based on the ICF framework and is consistent with the understanding of rehabilitation as a health strategy, complementing the preventive, curative and supportive health strategies (Meyer et al., 2011; Stucki et al., 2007a).

The WRD calls on countries ‘to organize, strengthen, and extend comprehensive rehabilitation services and programmes’ (2011, p. 95) and to strengthen rehabilitation research. A specific recommendation of the WRD is to develop ‘models of service provision that encourage multidisciplinary and client-centred approaches’ (2011, p. 123). This recommendation exactly represents the aim of Interprofessional Rehabilitation, edited by the three renowned experts in rehabilitation theory and practice: Sarah Dean, Richard Siegert and William Taylor.

Their book is the first work that provides rehabilitation practitioners and researchers with an in-depth discussion of the use of the ICF as a framework and as a language to structure the interprofessional rehabilitation process in interaction with the person in need of rehabilitation. The book comprehensively covers our current understanding of rehabilitation management, including an in-depth discussion of goal setting and a primer on the principles of outcome measurement. Most importantly, the book ­provides a chapter on ‘The person in context’, emphasizing and explaining what is referred to as ‘in partnership between person and provider and in appreciation of the person’s perception of his or her position in life’ in the revised version of the ICF-based ­conceptual description of the rehabilitation strategy (Meyer et al., 2011, p. 767).

Wisely, the authors have decided to focus on core themes essential for a better understanding of interprofessional rehabilitation in light of the paradigm shift, from seeing disability either solely as the impact of a health condition or of the social ­environment, towards an integrative and universal model of functioning and disability. The sections on controversies, as well as the case studies, are a key strength of this book. They bring current debates – for example with respect to our understanding of activity and participation or with respect to the distinction of functioning versus ­quality of life – to the attention of the reader.

This book is proof that rehabilitation research, while still in its infancy, is well on its way towards becoming a truly scientific endeavour. Let me join the editors in their call to all readers to contribute to what, based on the ICF, can now be called ‘human functioning and rehabilitation research’ (Stucki et al., 2007b).

References

Meyer. T., Gutenbrunner, C., Bickenbach, J. E., Cieza, A., Melvin, J. and Stucki, G. (2011) Towards a conceptual description of rehabilitation as a health strategy. Journal of Reh­abilitation Medicine, 43, 765–769.

Stucki, G., Cieza, A. and Melvin, J. (2007a) The International Classification of Functioning, Disability and Health: a unifying model for the conceptual description of the rehabilitation strategy. Journal of Rehabilitation Medicine, 39(4), 279–285.

Stucki, G., Reinhardt, J. D., Grimby, G. and Melvin, J. (2007b) Developing ‘Human Functioning and Rehabilitation Research’ from the comprehensive perspective. Journal of Rehabilitation Medicine, 39(9), 665–671.

United Nations General Assembly. (2006) Convention on the Rights of Persons with Dis­abilities. Resolution 61/106. New York: United Nations

World Health Assembly. (2005) Disability, including Prevention, Management and Reh­abilitation. Resolution 58.23. Geneva: World Health Assembly.

World Health Organization. (2001) International Classification of Functioning, Disability and Health. Geneva: WHO.

World Health Organization, The World Bank. (2011) World Report on Disability. Geneva: WHO.

Gerold Stucki, MD, MSProfessor and Chair, Department of Health Sciences and Health Policy,University of Lucerne, Lucerne, Switzerland,Director, Swiss Paraplegic Research and ICF Research Branchof the WHO FIC CC in Germany (at DIMDI), Nottwil, Switzerland

Preface

We wrote this book with the aim of providing a concise and readable introduction to the principles and practice of an interprofessional approach to rehabilitation that places the patient or client in their specific personal context. It is our belief that effective rehabilitation is best conducted by well-integrated teams of specialists working in an interdisciplinary way with the client or patient actively involved in all stages of the process. It is our hope that we will convince most of the readers of this book to share in this belief. However, beliefs are just that – beliefs – and they not to be confused with facts. So we would like to preface this book by giving some explanation for our own belief in the notion that rehabilitation is, or should be, both interprofessional and person centred.

We base this belief on three different strands of evidence. The first is our own subjective personal experiences of working as health professionals in various rehabilitation settings. The second line of evidence is also rather subjective in nature although it does at least involve a much larger sample size. It is the consensus wisdom, gleaned from several hundred experienced health professionals working in rehabilitation, who have completed and contributed to the courses in rehabilitation that we teach. The third source of evidence for our belief in the interprofessional, person-centred approach to rehabilitation is more objective and so has more scientific credibility. It stems from the growing body of published research on rehabilitation and its many facets. Much of this research will be summarized, analysed, debated and critiqued in the following pages as we outline our own perspective on rehabilitation. In reading this new text Interprofessional Rehabilitation: A patient centred-approach we would like to invite you, the reader, to adopt a similar three-pronged strategy in accepting or rejecting our belief in the person-centred and interprofessional nature of rehabilitation.

In other words we ask that you read the book and examine its message in the light of three separate kinds of evidence: (1) your own day-to-day clinical experience, (2) the opinions of workmates and colleagues from your own and allied disciplines, and (3) the scientific evidence. In many respects the purpose of this book is to provide the third component i.e. the scientific or research evidence. What the book cannot provide is the more ‘subjective’ evidence for a belief in a person-centred, interprofessional approach to rehabilitation. As we noted above, this kind of evidence is best found through your own thinking and reflection about your clinical practice and also through discussions and debates with colleagues. We hope that this book offers some challenges to your ways of thinking and provides a sound introduction to person-centred interprofessional rehabilitation based upon a firm scientific evidence base. We also hope that you will supplement this evidence by testing most of what you read against your own daily experience in the clinic and through discussions with your colleagues and patients. In particular we welcome your feedback, suggestions, ­comments, criticism, praise, insights and anecdotes about how you found this book helpful or otherwise in your workplace.

Sarah G. Dean, Richard J. Siegert and William J. Taylor

Acknowledgements

We gratefully acknowledge current and previous staff of the Rehabilitation Teaching and Research Unit, University of Otago, Wellington in New Zealand, who have made significant contributions to the ideas expressed in this book. In particular, we would like to acknowledge the seminal contribution of Professor Kath McPherson and Dr Harry McNaughton for their vision of interprofessional education in rehabilitation, as well as Dr Jean Hay-Smith, Ms Ginny Hickman, Dr William Levack, Dr Sue Lord, Ms Anne Sinnott and Professor Mark Weatherall for their contribution in ­identifying and developing the five core themes promoted in this book.

We also acknowledge and thank Dr Anna Sansom for her assistance with preparing the manuscript.

Dr Sarah Dean’s time was partially supported by the National Institute for Health Research (NIHR) UK. However, the views expressed are those of the author and not necessarily those of the NIHR or the UK Department of Health.

Financial support for Professor Richard Siegert’s time in the preparation of the manuscript was provided by the Dunhill Medical Trust and the Luff Foundation.

Chapter 1

Introduction

Richard J. Siegert,1William J. Taylor2and Sarah G. Dean3

1Professor of Psychology and Rehabilitation, School of Rehabilitation and Occupation Studies and School of Public Health and Psychosocial Studies, AUT University, Auckland, New Zealand;2Associate Professor in Rehabilitation Medicine, Rehabilitation Teaching and Research Unit, University of Otago Wellington and Consultant Rheumatologist and Rehabilitation Physician, Hutt Valley District Health Board, Wellington, New Zealand;3Senior Lecturer in Health Services Research, University of Exeter Medical School, United Kingdom

1.1 What is rehabilitation?

As academics we are in the habit of defining any important terms that we use in our teaching or research publications and this is a practice that we expect from our students in their assignments. So it is hard to avoid starting a textbook on rehabilitation without defining precisely what we mean by this word. But at the same time a part of us already knows that we are doomed to fail in this rather ambitious task. Why this sense of pessimism?

It may be that it stems from our having sat through too many lengthy and heated discussions at learned conferences about how best to define rehabilitation. It is actually hard to find the right words to capture all the meanings that rehabilitation has for different people. It is especially hard to do this in a few pithy sentences since we all have different perspectives on rehabilitation depending on whether we are a health professional, a client or patient, a caregiver or relative of a patient, or a health ­manager with budgetary responsibility.

Or it might come from the knowledge that the field subsumes such a wide range of diseases and health conditions across the lifespan and such a growing range of methods for assessing and intervening in these conditions. So the physiotherapist who works with a 7-year-old boy with cerebral palsy to improve his gait is engaging in rehabilitation. Similarly the nurse who specializes in continence management in adults with multiple sclerosis is engaged in rehabilitation. But what about the ­physiotherapist who works with an elderly man in the end stage of heart failure to maximize his strength, mobility and quality of life? Is this rehabilitation or palliative care?

Notwithstanding these concerns we shall begin this text on rehabilitation with a fairly searching consideration – what exactly is rehabilitation. To do this we will first clarify what rehabilitation is not – or at least what we the authors do not include as rehabilitation for the purposes of this book. Then we will consider a number of definitions that other authors have offered and attempt to tease out some of the key ideas that they share and also the problematic issues in arriving at a consensus definition of rehabilitation. Next, we will introduce the five core concepts that lie at the heart of this book. These core concepts will, to a large extent, define what we understand by the term rehabilitation. However, we will not conclude this chapter by selecting or proposing a single, ‘best’ definition of rehabilitation. Rather, we prefer to let all these definitions and concepts, ideas and opinions, percolate for a time while we examine our core themes in depth. Having completed that journey we will then ask you, in Chapter 7, to revisit the issue of how we might best define rehabilitation.

1.2Setting boundaries – or what we don’t mean by rehabilitation

The word ‘rehabilitation’ has become a buzzword in the early 21st century. Wherever you look there is somebody using the word rehabilitation. But depending on who is talking or writing, who is being rehabilitated and the context in which they are using it, the meaning can vary considerably. Hardly a day goes by without us reading in the tabloid press about the latest film star or pop singer to go into ‘rehab’. Our daily papers also feature heated arguments in the Letters to the Editor section about the merits of spending taxes on trying to ‘rehabilitate’ hardened criminals – or whether we should simply be locking them away for longer sentences. Not so long ago dissident politicians in some communist countries occasionally disappeared from public life only to reappear some years later having been politically ‘rehabilitated’. A famous example of this was Deng Xiaoping who fell from grace during the Cultural Revolution but was later ‘rehabilitated’ and eventually became the leader of the People’s Republic of China. In searching electronic databases for our own research, using rehabilitation as keyword, we discovered that the term is also commonly used for the process of restoring land that has been ravaged by mining.

Interestingly, although none of these uses of the word have any great relevance for our text, they do all convey the sense of someone or something that has in some way become damaged or corrupted and then, through some prolonged process, has been restored to an acceptable or desirable state of existence.

However, we wish to be quite clear in this book, that in using the term rehabilitation, we are not referring to interventions for substance misuse problems, criminal offending, (perceived) political misdemeanours or natural environments devastated by human technology. In general we will use the term only for referring to ways of working with people who have some type of disability resulting from a congenital, traumatic or chronic health condition. Some examples of these conditions are ­amputations, cerebral palsy, chronic obstructive pulmonary disease, lower back pain, multiple sclerosis, myocardial infarction, Parkinson’s disease, spinal cord injury, stroke, schizophrenia and traumatic brain injury. However, this is starting to sound like a definition of rehabilitation, so it might be a good point to consider some of the ways in which other people have already defined the concept.

1.3Some definitions of rehabilitation

Chambers Twentieth Century Dictionary gives the following definition of rehabilitate ‘to reinstate, restore to former privileges, rights, rank etc,: to clear the charter of: to bring back into good condition, working order, prosperity: to make fit, after disablement or illness, for earning a living or playing a part in the world’ (Macdonald, 1974, p. 1138).

The word rehabilitation comes from the Latin root ‘habil’ meaning to enable. Rehabilitation therefore means to ‘re-enable’ or ‘restore’ and it is this sense of the word that is captured above in the diverse meanings attributed to it. However, our concern is primarily with the use of the word within healthcare and related settings. Rehabilitation is a relatively new term and specialty within healthcare (Gritzer and Arluke, 1985). One of the earlier definitions of rehabilitation within the healthcare realm is Jefferson’s (1941) statement that rehabilitation should be: ‘…the planned attempt under skilled direction by the use of all available measures to restore or improve the health, usefulness and happiness of those who have suffered injury or are recovering from disease. Its further object is to return them to the service of the ­community in the shortest time’ (Jefferson, 1941).

Notwithstanding its age, this statement of Jefferson’s captures a number of key ideas that are integral to the aims and purposes of contemporary rehabilitation practitioners. There is the implication that rehabilitation is a complex process demanding a high level of professional skill and a holistic view of the individual. It is also clear from this definition that rehabilitation is not just about restoring or improving the person’s physical health – their happiness is also vitally important. Even more contemporary is the assertion that rehabilitation enables the individual, not merely to feed and clothe themselves, but to participate as a citizen who makes an important contribution to their community.

Some 40 years after Jefferson, the World Health Organization (WHO), advanced the following definition: ‘Rehabilitation is a problem-solving and educational process aimed at reducing the disability and handicap experienced by someone as a result of disease, always within the limitations imposed by available resources and the underlying disease’ (cited in Wade, 1992, p. 11).

This definition highlights a shift in thinking about rehabilitation as largely a ­medical concern, to a broader concern with the person’s biological, psychological and social functioning i.e. the biopsychosocial model. Thus, rehabilitation is not simply a medical concern but requires the person to learn new skills and ways of coping with their changed circumstances. The following definition from Barnes and Ward (2000, p. 4) is very similar in emphasizing rehabilitation as an educational or learning ­process that has physical, psychological and social dimensions: ‘Rehabilitation can thus be defined as an active and dynamic process by which a disabled person is helped to acquire knowledge and skills in order to maximize physical, psychological, and social function. It is a process that maximizes functional ability and minimizes disability and handicap’.

The final definition that we wish to consider here comes from Sinclair and Dickinson (1998, p. 1): ‘a process aiming to restore personal autonomy in those aspects of daily living considered most relevant by patients, service users and their family carers’. This concise statement emphasizes two key elements of modern rehabilitation practice that will also be emphasized in this book. First, is the notion that the most important goals in the rehabilitation process are those that matter most to the client or patient and only they can identify these goals. The second is the awareness that the patient’s family, relatives, caregivers, friends etc. are important participants in a good rehabilitation programme.

1.4Some other issues in defining rehabilitation

Before introducing the five core themes of this book there are a couple of additional issues in defining rehabilitation that we need to consider. The first is the difference between therapy and rehabilitation. The second concerns a particularly strong challenge to traditional notions of rehabilitation and disability that arose in the 1970s.

Therapy versus rehabilitation

A major part of any programme of rehabilitation consists of the different kinds of therapies involved. These typically include occupational therapy, physiotherapy, and speech and language therapy (DeJong et al., 2005). These ‘core therapies’ may be supplemented with interventions offered by podiatrists, psychologists, social workers, family therapists, sport and exercise therapists, and experts in the use of assistive technologies. However, ‘doing’ therapy is not the same thing as ‘doing’ rehabilitation and rehabilitation is not just a synonym for therapies. Even worse is the assumption that after a spell in the neurosurgical, geriatric or orthopaedic ward, a patient enters ‘rehabilitation’ prior to discharge into the community.

The point at issue here is simply that rehabilitation means more than just physical therapy or spending two weeks in a ward with that name. It is actually about a com­prehensive approach to working with the person and their family. This kind of approach can occur in an acute setting, a designated rehabilitation ward and also in the community until long after discharge from hospital. Moreover, some therapists practice therapy without a rehabilitation approach whereas some non-therapists (e.g. family, friends, community nurses, general practitioners) play an active role in the rehabilitation process. In other words, although the various therapies are essential to rehabilitation, they are still only components of a broader and more complex process.

Disabling societies

Perhaps the strongest challenge yet to traditional medical understanding of how to best define rehabilitation has come from disability rights activists and academics in the field of disability studies (Braddock and Parish, 2001; Fougeyrollas and Beauregard, 2001). After the growth and influence of the civil rights movement in the USA in the1960s, the flourishing of the women’s movement in many countries, and an increasing awareness of the rights of psychiatric patients, the1970s were a period of rapid growth in political activism among disabled people. The 1970s also saw the emergence of the social model of disability (Braddock and Parish, 2001). There are different perspectives on what exactly the social model of disability is and its implications but the following quotation from David Pfeiffer captures its essence nicely: ‘Disability is not a medical nor a health question. It is a policy or political issue. A disability comes not from the existence of an impairment, but from the reality of building codes, educational practices, stereotypes, prejudicial public officials ( judges, administrators, direct care workers), ignorance, and oppression which results in some people facing discrimination while others benefit from those acts of discrimination’ (Pfeiffer, 1999, p. 106).

In this passage Pfeiffer is arguing that disablement is not merely the natural consequence of some biological defect within the individual but rather a form of discrimination or oppression that society inflicts upon those people who are perceived or labelled as physically or mentally impaired. Hence disability (and presumably rehabilitation too) is a political issue rather than just a medical or health issue. So, from this perspective, disability is more a reflection of how much a society values differences among people and allocates its resources to ensure that all people have the opportunity to participate fully in society. For example, disability is partly a product of architecture and buildings that for centuries were designed without even considering their accessibility for disabled people. Or to take another example, disability is a result of a competitive job market that actively or subtly discriminates against people with disabilities.

The arguments for and against a social model of disability are well beyond the scope of the present text (readers wishing to learn more about the social model of disability and different perspectives on it would do well to consult recent issues of the journal Disability and Society published by Taylor and Francis). However, the social model of disability has had a substantial and lasting impact on contemporary perspectives on rehabilitation. Evidence of this impact can be seen in the World Health Organization’s (WHO) system for the classification of the ‘consequences of disease’ and its evolution since 1980. One of the most noticeable changes in the evolution from the International Classification of Impairment, Disease and Handicap (ICIDH) through the ICIDH-2 to the current International Classification of Functioning (ICF) (WHO, 2001) is the greater emphasis that is given to the role of environmental factors (social and physical) in contributing to the process of disablement. Concomitant with this shift has been a transition from a largely biomedical or disease model to a biopsychosocial approach. Interestingly, the introduction to the ICF describes both the ­medical and the social models of disability and functioning and notes that the ‘ICF is based on an integration of these two opposing models’ (WHO, 2001, p. 20). We propose that the ICF provides a framework for rehabilitation, and is therefore the first core theme for this book (see Chapter 2).

The impact of the social model of disability is also reflected in the present book – most notably in Chapter 6, which is about the person in context. However, this book is written by academic health professionals, who have all worked in a range of rehabilitation settings, and so it will also reflect many aspects of the traditional medical model. There are risks involved in asserting that disability is purely a social construction and not a medical issue. One of these risks is that we ignore the reality that many disabled people are high frequency users of the health system. Their lives bring them into all too regular contact with health professionals. Consequently, in this book we adopt a perspective akin to that advocated by the ICF in which the aim is to bridge these two opposing viewpoints and to integrate biological, psychological and social elements of rehabilitation.

1.5The core themes

Having set the scene we now introduce the five core themes that make up the content of Chapters 2 to 6 of this book. As we have mentioned, the first theme concerns the ICF, how this can be used as a framework for rehabilitation and act as a model and classification system. This chapter has been written by William Taylor, a rheumatologist who has worked on the use of the ICF for people with psoriatic arthritis, and by Szilvia Geyh, a psychologist who has worked for the ICF Research Branch in ­co-operation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI – the German Institute of Medical Documentation and Information). William and Szilvia’s chapter describes the ICF, its development and terminology, and how it can be used for assessment and intervention evaluation. They go on to discuss the limitations and controversies about the ICF and its future development. The next theme concerns interprofessional rehabilitation and this chapter (Chapter 3) has been written by two allied health professionals who have worked clinically in rehabilitation settings (occupational therapy and physiotherapy) but who have also been lecturers involved with delivering interprofessional education. Claire Ballinger and Sarah Dean discuss teamwork and the roles and make-up of successful rehabilitation teams including service users.

After this, Chapter 4 goes on to describe the processes by which these teams engage in doing rehabilitation. William Levack, a physiotherapist, takes the lead on this chapter, and in particular provides a detailed account of one of the key processes in rehabilitation: goal setting. By the end of Chapter 4 we hope to have made it clear that the rehabilitation processes theme also includes the process of evaluating practice. Outcome evaluation is therefore the next core theme and this is covered in much more detail in Chapter 5 by Richard Siegert, an expert in the development and evaluation of rehabilitation outcome measures, and by Jo Adams, an occupational therapist with expertise in the development, application and research of outcome measures for people with hand impairments. Our final core theme, the person in context, is placed last in our list of themes, not because it is the least important but rather because it is the ultimate focus of all our themes. The earlier chapters all touch on how the patient, client or service user is the focus of rehabilitation and in Chapter 6 Julie Pryor, nurse and director of a Nursing Rehabilitation Research and Development Unit in Australia, leads the discussion on how to place the person in their context and the importance of this for successful and meaningful rehabilitation to take place.

1.6A word about terminology

Throughout the book we have asked our authors to consider the terminology they are using and to provide definitions as appropriate. However, in many instances there are several terms that can be used interchangeably, for example patient, client, or person can all be used to prefix ‘centred care’. Rather than attempt to be popular or to be prescriptive in our terminology, we will use whichever word provides the best fit for the sentence in question. For example, the term ‘patient-centred care’ is often used in this book because it clearly identifies the person in question, differentiating them from say, relatives or carers.

1.7Summary

The final chapter of this book (Chapter 7) revisits the key messages of our five core themes; identifies the limitations in current thinking and practice and suggests some of the likely developments for the future of rehabilitation. We hope that you will enjoy this book; it is not profession or discipline specific but does cover a range of examples from differing conditions, rehabilitation approaches and types of research. Thus, we believe there is something here for everyone involved in interprofessional rehabilitation.

References

Barnes, M. P. and Ward, A. B. (2000). Textbook of Rehabilitation Medicine. Oxford: Oxford University Press.

Braddock, D. L. and Parish, S. L. (2001). An institutional history of disability. In: G. L. Albrecht, K. D. Seelman and M. Bury. Handbook of Disability Studies. Thousand Oaks, CA: Sage Publications.

DeJong, G., Horn, S. D., Conway, B., Nichols, D. and Healton, E. B. (2005). Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and ­outcomes. Archives of Physical Medicine and Rehabilitation, 86(Supplement 1), 1–7.

Fougeyrollas, P. and Beauregard, L. (2001). An interactive person-environment social creation. In: G. L. Albrecht, K. D. Seelman and M. Bury. Handbook of Disability Studies. Thousand Oaks, CA: Sage Publications.

Gritzer, G. and Arluke, A. (1985). The Making of Rehabilitation: A Political Economy of Medical Specialization 1890–1980. Berkeley, CA: University of California Press.

Jefferson, G. (1941). Discussion on rehabilitation after injuries to the central nervous system. Proceedings of the Royal Society of Medicine, 35, 295–299.

Macdonald, A. M. (1974). Chambers Twentieth Century Dictionary. Edinburgh: W & R Chambers.

Pfeiffer, D. (1999). The categorization and control of people with disabilities. Disability and Rehabilitation, 21(3), 106–107.

Sinclair, A. and Dickinson, E. (1998). Effective Practice in Rehabilitation. London: King’s Fund Publishing.

Wade, D. T. (1992). Measurement in Neurological Rehabilitation. Oxford: Oxford University Press.

World Health Organization. (2001). International Classification of Functioning, Disability and Health:ICF. Geneva: World Health Organization.

Chapter 2

A rehabilitation framework: the International Classification of Functioning, Disability and Health

William J. Taylor1and Szilvia Geyh2,3

1Associate Professor in Rehabilitation Medicine, Rehabilitation Teaching and Research Unit, University of Otago Wellington and Consultant Rheumatologist and Rehabilitation Physician, Hutt Valley District Health Board, Wellington, New Zealand;2Affiliated Teaching Fellow, Department of Health Sciences and Health Policy of the University of Lucerne, Switzerland;3Group Leader at Swiss Paraplegic Research, Nottwil, Switzerland

2.1 There is a need for a common language of functioning

It is hard to overestimate the importance of good communication between ­rehabilitation health professionals from different disciplines involved in the care of the same client. The different ‘life worlds’ of people from diverse backgrounds can lead to talking past each other, miscommunication or misunderstanding. Imagine the following conversation at a weekly inpatient rehabilitation team meeting.

DOCTOR:

  When is Mr Brown likely to be ready to be discharged? He is walking well now and does not seem especially disabled.

PHYSIOTHERAPIST:

  Yes but he is still getting stronger and will be able to walk better if he receives more therapy. His ankle dorsiflexors are still not functioning very well at all.

NURSE:

  He is totally independent with self-cares.

DOCTOR:

  Well then we could plan to discharge tomorrow then.

OCCUPATIONAL

THERAPIST:

  He manages fine in the ward but he has stairs at home and I don’t know how well he will cope with that environment.

SOCIAL WORKER:

  He wants to be home as quickly as possible and back at work because financially things are tight for his family. He is actually doing some work in hospital since most of it is computer-based.

PHYSIOTHERAPIST:

  Well, what are the priorities – shouldn’t we be getting him as functional as possible? Isn’t that our job?

In this exchange, a number of words relating to the concept of ‘functioning’ are in italic. There appears to be different concepts about what this means among the different health professionals, yet many would probably agree with the physiotherapist’s belief that the primary task of rehabilitation is to maximize the person’s level of ‘functioning’. A key issue then, in order for rehabilitation teams to work productively together, is to agree upon what is meant by this important term. As we see in this hypothetical exchange, ‘functioning’ can refer to how well a person walks, the strength of a particular muscle, ability to perform a task within one environment ­compared with a different environment, self-care activities or actual performance of productive work.

The doctor and nurse seem to believe that accomplishment of a particular task (such as walking or self-care activities) renders the person non-disabled, irrespective of how difficult or how ‘well’ that task is managed. Furthermore, they ignore the ­possibility that a person can function quite well in one environment but not in another. Contextual factors are clearly more important than they realize. The occupational therapist is much more aware of the more nuanced notion of disability in which the environment can render the person disabled rather than the intrinsic abilities of the person. In such situations, improving a person’s function may have nothing to do with more therapy, but rather requires a change to the environment, such as building a ramp rather than steps. Functioning must therefore be seen as an interaction between the person and their context. One other important consideration of ‘context’, which was not raised by the team discussion, is the context of the person himself. That is, what attributes (not directly related to the issue at hand) does the client bring. This can involve his age, co-morbidities and personality traits among a range of ­possibilities. This context too is very important in determining the actual functioning of the person.

The social worker introduces two additional concepts. The first concerns a distinction between more basic activities such as walking and those that are more societal in orientation – fulfilling a role such as paid work or being part of a family. Accomplishing such a role may often have little relation to more basic activities, and therefore cannot be seen as hierarchical. In this example, it is simply not necessary for the person to be able to walk well in order for him to perform his paid work. Of course, in other kinds of work, walking will be a pre-requisite. But the relationship between specific disturbances of basic activities (which we might consider as those occurring at the level of the whole organism), and other kinds of activities such as work (which we might consider at the level of organism within his/her social world) cannot be assumed and needs to be evaluated carefully as part of good rehabilitation practice for each client. The second concept that the social worker introduces is the notion of ‘actual performance’ perhaps, as if this was a more impressive observation than ‘is capable of’. Certainly, the two concepts are distinct. Direct observation of performance is possible but determining capacity is rather more judgemental and involves making a prediction rather than describing what is observed. Whether observation of performance is better than prediction of capacity is unclear and almost certainly depends upon what the evaluation is used for – is it fit for purpose? Often a determination of performance is not possible, since the particular activity occurs very infrequently or is potentially dangerous. For example, how could the team respond to Mr Browns’s request for some guidance as to whether he can engage in his hobby of skydiving?

Returning to the physiotherapist again, the common use of the term ‘function’ that is synonymous with ‘operate’ means that how well or poorly parts of the organism are working also comes under the umbrella of ‘function’. Again, the relationship between the operation of parts of the organism and the whole of the organism are not ­necessarily hierarchical or linear. Walking is possible without all components of the walking mechanism working normally (or at all). Entire loss of a lower limb does not preclude walking. It is often critically important for therapists to consider carefully the primary targets of their treatment and to constantly re-evaluate the relevance of that target in relation to the overall rehabilitation plan.

It is clearly necessary, therefore, to organize these different concepts of ‘­functioning’ into a schema that all disciplines can understand and use. We might consider this a common language of functioning where each term is precisely defined and meaningful across the different discipline-specific languages. For example, when ­occupational therapists talk about the ‘Model of Human Occupation’ (Kielhofner, 2008), can the language be translated into the same terms that psychologists would use when ­discussing ‘cognitive–behavioural therapy’?

From the perspective of populations, healthcare systems and payers such a ­language is also important. For example, a means of how to classify, categorize and enumerate all the ways people are affected by health conditions is necessary in order to properly understand the health and functioning of a population. A descriptive ­language that contains all the manifestations of health and disease would be complementary to a descriptive system of pathological diagnoses contained within the International Classification of Disease (ICD) (WHO, 1992).