Rehabilitation

Introduction

Rehabilitation (rehab) is a process of care aimed at restoring or maximizing physical, mental, and social functioning. Can be used for:

Acute reversible insults, eg sepsis
Acute non-reversible or partially reversible insults, eg amputation, MI
Chronic or progressive conditions, eg Parkinson’s disease

Involves both restoration of function and adaptation to reduced function depending on how much reversibility there is in the pathology. Rehabilitation is an active process done by the patient not to him/her. It is hard work for the patient (akin to training for a marathon)—it is not ‘convalescence’ (akin to a holiday in the sun).

Rehabilitation is the ‘secret weapon’ of the geriatrician, poorly understood and little respected by other clinicians. Many geriatricians feel it is what defines their specialty and it can certainly be one of the most rewarding parts of the job. The ‘black box’ of rehabilitation contains a selection of non-evidence-based, common sense interventions comprising:

Positive attitude. Good rehabilitationalists are optimists—this is partly because they believe all should be given a chance and partly because they have seen very frail and disabled older people do well. A positive attitude from the team and other rehabilitating patients also improves the patient’s expectations. Rehabilitation wards should harbour an enabling culture where the whole team encourages independence: patients dressed in their own clothes, with no catheter bags on show and eating meals at a table with other patients
MDT coordinated working. By sharing goals the team can ensure all team members are consistent in their approach
Functionally based treatment, eg the haemoglobin level only matters if it is making the patient breathless while walking to the toilet
Individualized holistic outcome goals. These incorporate social aspects which are often neglected. The team concentrates on handicap rather than impairments (see Box 4.1)

Settings

Specialized rehabilitation wards are not the only place for rehab. If the considerations outlined are in place then successful rehabilitation can take place in:

Acute wards
Specialist wards (eg stroke units, orthopaedic wards)
CHs
DHs
Nursing and residential homes
The patient’s own home

These alternative sites often employ a roving rehabilitation team, which may be based in a hospital or the community.

Box 4.1 World Health Organization (WHO) classification (1980)

IMPAIRMENT—pathological defect in an organ or tissue, eg homonymous hemianopia due to posterior circulation stroke

DISABILITY—restriction of function due to impairment, eg inability to drive due to visual defect

HANDICAP—the social disadvantage cause by disability, eg unable to visit friends in neighbouring village as unable to drive

It can be seen that some impairments produce no disability or handicaps and some handicaps are due to multiple interacting impairments. The system allows the social circumstances to be factored in, such as in the examples given, the disability produces no handicap if a regular bus route exists. Doctors are generally focused on impairments, poor at assessing disability, and rarely consider handicap.

Despite the attractive logic of such a classification, it is actually rarely used in clinical practice. This is probably because geriatricians intuitively consider the wider aspects of illness without requiring the discipline of formal terms. The word ‘handicapped’ is now avoided due to negative connotations and stigma. The WHO issued a new classification of Functioning, Disability and Health in 1999 which is a little more complex but has a broadly similar structure (

www.who.int/classifications/icf/en/index.html).

The process of rehabilitation

1. Selection of patients

See

‘Selecting patients for inpatient rehabilitation’, p.80.

2. Initial assessment

This is not like a medical clerking, you need to get to know your patient on different levels (eg their mood, motivation and expectations, complex social factors). Remember it is more meaningful to assess the handicap not just the impairment.

3. Goal setting

See

‘Aims and objectives of rehabilitation’, p.75.

4. Therapy

Medical—doctor led (see ‘Doctors in the rehabilitation team’, p.94)
Physical—mainly physiotherapy (see ‘Physiotherapy’, p.86) and nurse led (see ‘Nurses in the rehabilitation team’, p.95). Mobility, balance, and stamina. Confidence is often a key issue
Self care—mainly occupational therapy (see ‘Occupational therapy’, p.91) and nurse led
Environmental modification—aids and adaptations
Carer/relative training—it is too late to leave this until just prior to discharge

5. Reassessment

Usually at weekly MDT meetings (see

‘HOW TO … Conduct a MDT meeting’, p.84). Goals are adjusted and new goals are set. Points 3, 4, and 5 are repeated in a cycle until the patient is ready for discharge.

6. Discharge planning

See

‘HOW TO … Plan a complex discharge’, p.83—should be started as soon as the patient is admitted but the efforts escalate towards the end of the inpatient period. A home visit and family meeting are often held to clarify issues.

7. Follow-up and maintenance

Post-discharge DVs, outpatients or DH attendance. Ideally done by the same team but in reality this function often taken over by community, in which case good communication is vital.

Aims and objectives of rehabilitation

It is essential that the MDT, ideally in conjunction with the patient, states what it plans to do and to achieve, in clear terms that are shared within the team and can be worked towards. A large part of this is achieved through the agreement and statement of targets at two hierarchical levels: aims and objectives.

Aims

Best set by the team, in discussion with the patient. One or two, patientcentred targets that encompass the broad thrust of the team’s work—a team ‘mission statement’ for that individual, eg:

To achieve discharge home, with the support of spouse, at 6 weeks
To transfer easily with the assistance of one, thus allowing return to existing residential home place at 4 weeks

Objectives

Best set by individual team members, in discussion with patient. More focused targets, usually several, that reflect specific disabilities and help focus the team’s specific interventions, eg:

To walk 10m independently, with a single stick, at 3 weeks
To achieve night-time urinary continence at 4 weeks

Both aims and objectives should have five characteristics, summarized by the acronym ‘SMART’:

Specific, ie focused, unambiguous
Manageable, ie amenable to the team’s influence
Achievable and
Realistic, acknowledging time and/or resource limitations. It is futile and demoralizing to set targets that cannot be achieved. Conversely, the team (and patient) should be ‘stretched’, ie the target should not be inevitably achievable
Time-bounded. Specify when the target should be achieved. Many patients are motivated and cheered by the setting of a specific date (especially for discharge). Setting dates for specific functional achievements prompts further actions, eg ordering of equipment for the home

Predicted date of discharge (PDD)

Specifying a PDD from the point of admission is useful for patients, carers and MDT members.

Emphasizes to the patient that inpatient care is not indefinite, and that a more pleasant home or care home environment is the aim
Can be intrinsically motivating for patient and team
Prompts carers and MDT to think ahead to pre- and post-discharge phases of care

Measurement tools in rehabilitation

Principles

The most widely used standardized measurement instruments are structured questionnaires that deliver a quantitative (numerical) output. They vary in precision, simplicity, and applicability (to patient groups or clinical settings). For each domain of assessment several tools of differing size are usually available, reflecting tensions between brief assessments (speed, easy-to-use, well-tolerated) and a more prolonged evaluation (precision improved, give added layers of information).

Measurement tools are helpful at single points (especially entry and exit to a therapy programme), and also in assessing progress and in guiding discussion around likely discharge destination.

Advantages

Quantify
Widely understood, and transferable across boundaries
Facilitates communication between professionals and settings of care
Provide a synopsis
May permit a less biased, more objective view of the patient
Facilitate a structured approach to assessment and clinical audit

Disadvantages

May be time-consuming
Scores may conceal considerable complexity—patients scoring the same may be very different
Intra-individual, intra-rater and inter-rater variabilities mean that a score may change whilst a patient remains static, eg, 3 or 4 points change in the (20-point) Barthel is needed before a team can be absolutely confident that the patient has changed
There are many scales available, and some are not in general use, leading to confusion when staff or patients move between units

Measurement instruments

Activities of daily living (ADLs)

Personal ADLs (pADLs) or basic ADLs (bADLs). Include key personal tasks, typically transfers, mobility, continence, feeding, washing, dressing. A single scale is valid for all.

The commonest is the Barthel (see Appendix, ‘Bartel Index’, p.688). Score range 0 (dependent) to 20 (independent). It is quick, and apparently simple to use but is not very sensitive to change, as steps within each domain (eg transfers) are large. A marked ceiling effect is seen, especially for a range of impaired patients living independently at home, many of whom score 20
The Function Independence Measure (FIM) takes longer to complete but is more sensitive to change during rehabilitation and can be useful in predicting length of stay and discharge destination

Extended activities of daily living (eADLs)

Also known as Instrumental ADLs (iADLs). Include key daily household tasks, eg housework, shopping. Useful for the more independent person. Scales are selected according to an individual patient’s needs, eg Frenchay Activities Index, Nottingham ADL Score.

Mobility

For example: Elderly Mobility Scale (EMS), Tinetti Mobility Score (TMS), timed get up and go test.

Cognition

Several screening and assessment tools are in common use
The 10-point AMTS, see Appendix, ‘The abbreviated mental test score’, p.690) is brief, and useful for screening in both outpatient and inpatient settings
Clock drawing tests (see Appendix, ‘Clock-drawing and the Mini-Cog™’, p.693) are alternative screening tests
The 30-point MMSE provides sufficient precision to be used for serial assessment—eg tracking recovery from delirium, or therapeutic response to cholinesterase inhibitors in dementia—but takes <10min to administer
The Middlesex Elderly Assessment of Mental State assesses systematically the major cognitive domains, using a range of targeted subtests. Time-consuming (15min), but gives more detailed information. Often used by therapists

Depression

For example, the GDS. Several versions of this are available, but the most commonly used is the 15-point score (see

Appendix, ‘Geriatric Depression Scale’, p.687), administered in 5-10min. Superficially distressing questions, but well tolerated by most patients. Sensitive (80%) but only moderately specific (60%).

Nutrition

The Malnutrition Universal Screening Tool (MUST) (see

Appendix, ‘Malnutrition universal screening tool (MUST)’, p.695) is widely used to screen inpatients and is superior at predicting malnutrition than weight alone.

Pressure area risk

Prompt systematic evaluation of patients at risk, and brisk response in those at risk, is essential. Several scores are available, but the most widely used is the Waterlow Pressure Sore Prevention Score, a summary score derived from easily available clinical data. High score indicates high risk. Note that the score does not take into account the ability of the patient to lessen risk by changing position, the acuity of the medical condition, etc.

Disease-specific scales

All of the common diseases have dedicated scales, usually developed for use in research, and then introduced variably into clinical practice. They are often more complex than used in general clinical practice, with corresponding disadvantages—time-consuming, less easily transferable. For example the Unified Parkinson’s Disease Rating Scale (UPDRS) quantifies all the motor and behavioural aspects of the disease as a single number.

Selecting patients for inpatient rehabilitation

Most hospitals do not have enough rehabilitation beds to cater for all patients who could benefit, so these beds are a valuable resource. This is often not understood by the patients, relatives, or referring service. Patient selection is a time-consuming, important, and complex task. Where there is no cost limit, the approach can be more inclusive.

Who should select patients?

Review of referrals is often done by geriatricians, but can equally well be done by another experienced rehabilitation professional. In some cases, a team assessment is done and discussed in a conference.

Who to choose?

This is difficult. Be aware that some services will refer simply to get the patient out of one of their beds. Two factors need to be considered:

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