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What is rehabilitation? An empirical investigation leading to an evidence-based description

  • Oxford Centre for Enablement


Background There is no agreement about or understanding of what rehabilitation is; those who pay for it, those who provide it, and those who receive it all have different interpretations. Furthermore, within each group, there will be a variety of opinions. Definitions based on authority or on theory also vary and do not give a clear description of what someone buying, providing, or receiving rehabilitation can actually expect. Method This editorial extracts information from systematic reviews that find rehabilitation to be effective, to discover the key features and to develop an empirical definition. Findings The evidence shows that rehabilitation may benefit any person with a long-lasting disability, arising from any cause, may do so at any stage of the illness, at any age, and may be delivered in any setting. Effective rehabilitation depends on an expert multidisciplinary team, working within the biopsychosocial model of illness and working collaboratively towards agreed goals. The effective general interventions include exercise, practice of tasks, education of and self-management by the patient, and psychosocial support. In addition, a huge range of other interventions may be needed, making rehabilitation an extremely complex process; specific actions must be tailored to the needs, goals, and wishes of the individual patient, but the consequences of any action are unpredictable and may not even be those anticipated. Conclusion Effective rehabilitation is a person-centred process, with treatment tailored to the individual patient’s needs and, importantly, personalized monitoring of changes associated with intervention, with further changes in goals and actions if needed.
Clinical Rehabilitation
1 –13
© The Author(s) 2020
Article reuse guidelines:
DOI: 10.1177/0269215520905112
What is rehabilitation? An
empirical investigation leading
to an evidence-based description
Derick T Wade
Background: There is no agreement about or understanding of what rehabilitation is; those who pay for
it, those who provide it, and those who receive it all have different interpretations. Furthermore, within
each group, there will be a variety of opinions. Definitions based on authority or on theory also vary and
do not give a clear description of what someone buying, providing, or receiving rehabilitation can actually
Method: This editorial extracts information from systematic reviews that find rehabilitation to be
effective, to discover the key features and to develop an empirical definition.
Findings: The evidence shows that rehabilitation may benefit any person with a long-lasting disability,
arising from any cause, may do so at any stage of the illness, at any age, and may be delivered in any setting.
Effective rehabilitation depends on an expert multidisciplinary team, working within the biopsychosocial
model of illness and working collaboratively towards agreed goals. The effective general interventions
include exercise, practice of tasks, education of and self-management by the patient, and psychosocial
support. In addition, a huge range of other interventions may be needed, making rehabilitation an extremely
complex process; specific actions must be tailored to the needs, goals, and wishes of the individual patient,
but the consequences of any action are unpredictable and may not even be those anticipated.
Conclusion: Effective rehabilitation is a person-centred process, with treatment tailored to the individual
patient’s needs and, importantly, personalized monitoring of changes associated with intervention, with
further changes in goals and actions if needed.
Rehabilitation description, content, process, therapy, person-centred
Date Received: 15 January 2020; accepted: 18 January 2020
Oxford Institute of Nursing, Midwifery and Allied Health
Research (OxINMAHR) and Movement Science Group,
Faculty of Health and Life Sciences, Oxford Brookes
University, Oxford, UK
Corresponding author:
Derick T Wade, Oxford Institute of Nursing, Midwifery and
Allied Health Research (OxINMAHR) and Movement Science
Group, Faculty of Health and Life Sciences, Oxford Brookes
University, Headington Campus, Gypsy Lane, Oxford OX3
0BP, UK.
Twitter: @derickwaderehab
905112CRE0010.1177/0269215520905112Clinical RehabilitationWade
2 Clinical Rehabilitation 00(0)
What constitutes rehabilitation? Physiotherapy?
Exercises? Something you receive ‘to get you bet-
ter’? Many healthcare staff, when referring someone
to rehabilitation, have little idea, maybe saying
‘they’ll sort out your problems for you’, or some-
times ‘they’ll work you really hard’. Commissioners,
similarly, rarely understand what they are paying
for; at most they expect a certain number of contact
hours between a patient and a therapist and/or set-
ting goals. Patients do not know what to expect.
Searching dictionaries or the Internet does not
help much because the answers are imprecise and
lack detail. Commissioners (for example) still
would not know what they are paying for, how to
assess its quality, or how to quantify it if depending
on published definitions, such as one in a recent
commissioning guide1 (Box 1), or others.2–4 Most
definitions are not based on evidence.
Box 1.
A definition of rehabilitation
From NHS England’s guide on commissioning rehabilitation1
The goal:
A modern healthcare system must do more than just stop people dying. It needs to equip them [patients] to
live their lives, fulfil their maximum potential and optimise their contribution to family life, their community
and society as a whole.
The content:
Rehabilitation achieves this by focusing on the impact that the health condition, developmental difficulty
or disability has on the person’s life, rather than focusing just on their diagnosis. It involves working in
partnership with the person and those important to them so that they can maximise their potential and
independence, and have choice and control over their own lives. It is a philosophy of care that helps to
ensure people are included in their communities, employment and education rather than being isolated from
the mainstream and pushed through a system with ever-dwindling hopes of leading a fulfilling life.
An empirical investigation into the phenome-
non of rehabilitation might clarify the matter. This
editorial reviews studies reporting that rehabilita-
tion has a beneficial effect and asks: what aspects
of the intervention being studied, rehabilitation, are
common between the various studies investigating
successful rehabilitation?
This approach is not new. It was used to investi-
gate the nature of ‘stroke unit rehabilitation’ in
2002,5 and the 2013 review6 stated:
In summary, organised inpatient (stroke unit) care was
characterised by: (1) co-ordinated multidisciplinary
rehabilitation, (2) staff with a specialist interest in
stroke or rehabilitation, (3) routine involvement of
carers in the rehabilitation process and (4) regular
programmes of education and training.
This editorial, based on systematic reviews and
larger individual trials, identifies the features of
rehabilitation found in studies showing that patients
benefit. Its aim is to discover the main characteris-
tics of effective ‘rehabilitation’. The results are
presented in three domains:
Context: who may benefit, and does location
Process: what are the common features of the
Interventions: what interventions are used?
It develops an evidence-based description of
effective rehabilitation.
This part investigates whether the benefits of reha-
bilitation are restricted to specific patient groups,
or to delivery in specific locations.
Wade 3
What conditions are associated with
Systematic reviews have considered rehabilitation
involving patients covering a large range of condi-
tions, diseases, and ages, and in almost all groups a
positive effect is shown. Patients can be helped by
rehabilitation if they have the following:
Pulmonary and respiratory conditions;7–9
Cardiac10,11 conditions;
Neurological conditions such as multiple scle-
rosis,12–14 stroke,6 motor neurone disease,15 and
other conditions;16,17
Musculo-skeletal disorders such as fractures,18,19
hip and knee arthroplasty,20 and sub-acute or
chronic back pain;21,22
The common feature among the wide variety of
disease disorders listed above is that the patient has
a continuing disability, often with several or many
factors contributing to the situation.
The only reasonable conclusion must be that
rehabilitation, whatever it is, is likely to benefit
anyone with persistent disability associated with an
illness, regardless of the underlying disease or
Is rehabilitation effective anywhere?
Rehabilitation has been found effective in most
Probably in intensive care units (there are many
reviews, with contrasting findings);25–28
Specialist rehabilitation inpatient wards;6
Out-patient and day-hospital settings;29,30
Nursing homes;31 and
At home.32–34
It is specifically important to note that reha-
bilitation out of hospital, after discharge, is
Although the strength of the evidence varies,
there seems little doubt that rehabilitation can have
a beneficial effect wherever it is delivered. Direct
comparisons between different settings have rarely
been studied.
Does stage or prognosis of disease affect
Categorization of disabling disorders by progno-
sis and stage is difficult, and the categories sug-
gested are not as distinct as they appear. Moreover,
the effects of development (in children) and aging
(in older adults) lead to changes in disability and/
or rehabilitation needs. Nonetheless, there is evi-
dence that rehabilitation is beneficial in the
The acute phase of sudden onset disorders;
stroke,6 acute episodes of coronary artery dis-
ease,10 hip fracture,18 and traumatic brain injury;16
including those where there is no ‘natural
recovery’, such as spinal cord injury where
rehabilitation has transformed life expec-
tancy and social functioning.36,37
The later, more stable phases of acute onset dis-
orders: stroke;38
Diseases that have a slow or fluctuant onset and
are progressive to a greater or lesser degree:
multiple sclerosis,12–14 osteoarthritis,39 chronic
back pain;21
Diseases that are more inexorably progres-
sive: Parkinson’s disease17 and Alzheimer’s
One may conclude that rehabilitation is likely to
be beneficial to a person with disability at any stage
of their illness and whatever the nature of their
prognosis, including when receiving palliative care:
rehabilitation can benefit people with advanced
Does age limit effectiveness?
There are few trials of rehabilitation (in contrast to
trials on specific interventions) involving children,
and no reviews were identified. The studies
already referred to have included people of all
ages from teenagers through to the very old and
frail. There is no reason to doubt that rehabilitation
4 Clinical Rehabilitation 00(0)
is effective at any age, though there is little evi-
dence for children.
The second part of this review investigates what
features of the process are common across the stud-
ies showing benefit.
Using the biopsychosocial model of
The use of a biopsychosocial framework43 is men-
tioned or implied in almost all reviews and articles.
This characteristic is inextricably intertwined with
multidisciplinary teamwork44 because any process
based on the biopsychosocial model necessarily
considers a wide range of factors, requiring input
from several different professions. Conversely, any
team covering the range of factors in the model
necessarily uses a single framework for analysis
and communication.
The use of this model43 is perhaps the defining
characteristic of rehabilitation and distinguishes
it from most other medical specialist services.
Other healthcare services using the biopsychoso-
cial model, to a greater or lesser extent, are psy-
chiatry, including learning disability and liaison
psychiatry services; palliative care; chronic pain
services; geriatrics; and probably community
Practicing multidisciplinary teamwork
In almost all the studies and reviews of rehabilita-
tion, the involvement of a multidisciplinary team44
is mentioned explicitly or, if not, it is implied. The
important features associated with multidiscipli-
nary teamwork are also expanded upon in the
stroke rehabilitation reviews.5,6
The need for and characteristics of multidisci-
plinary teams has been reviewed recently.44 Studies
suggest that, in healthcare, teamwork is generally
associated with a better outcome,45 and an observa-
tional study on stroke rehabilitation teams46 found
a relationship between better outcome and three
team features:
Being oriented towards achieving tasks;
Extent of order and organization;
Use of good-quality information.
Another study on stroke rehabilitation teams47
found that effectiveness improved as the quality
of team meetings improved in terms of the
Contributions being equal;
Mutual support;
Commitment of members to team goals;
Cohesion (team spirit).
The evidence thus strongly suggests that suc-
cessful rehabilitation depends upon a multidiscipli-
nary team being involved. It is important to stress
that a team is not just a collection of people who
happen to be working with a specific patient; a
team works together with each other over time and
with many patients.44
It is also important to recognize that the team
must have specialist expertise (knowledge and
skills) in the problems that they see. In the case of
stroke unit rehabilitation, this was related to
stroke,5,6 but in other setting, it might be a condi-
tion, such as chronic pain or spinal cord injury, or a
particular intervention such as assistive technol-
ogy, or some other particular aspect of rehabilita-
tion. Acquiring and maintaining specialist expertise
requires continuing multidisciplinary education
and training (i.e. training in areas outside each per-
son’s limited professional field).5,6
Other important characteristics associated with
effective teamwork44 include the following:
Having regular team meetings, both
About individual patients, and
About team functioning and processes.
Using the setting of goals to:
Motivate the patient and team members.
Ensure co-ordination of actions between
different people and over time.
Working collaboratively to
Support each other’s interventions.
Wade 5
Share information, including specific knowl-
edge and skills.
Using structured protocols
Just as the evolution of the biomedical model of ill-
ness led to a very standardized way of approaching
the biomedical aspects of illness, with great suc-
cess, so a structured careful, almost obsessional
approach arising from considering all factors within
the biopsychosocial model of illness is an important
aspect of rehabilitation’s success. The team’s use of
structured approaches to common problems, be that
assessing a person’s losses and abilities, or reacting
to challenging behaviours, or communicating and
reporting on clinical matters is part of the ‘coordi-
nated approach’ identified in stroke services.5
The effectiveness of structured protocols is
perhaps illustrated most powerfully in the field of
spinal cord injury rehabilitation.36,37 Between
1935 and 1955, the prognosis for someone with a
spinal cord injury was transformed from an early
death, secondary to sepsis and renal failure, to
returning to community living and employment
with a reasonable (but not yet fully normal) life
expectancy. This arose in the absence of any treat-
ment for the injury or transformative medical
advance relating to the ‘complications’ that killed
people. Using structured protocols may also
account for the reduced mortality associated with
stroke unit care.6
Being person-centred (and family-
Two characteristics of successful stroke rehabilita-
tion were ‘routine involvement of carers in the
rehabilitation process’,6 and routine provision of
‘information on stroke disease, rehabilitation, and
recovery’ to both the patient and the family.5 Being
person-centred is also consistent with both goal-
setting and shared decision-making, both processes
that are widely advocated although perhaps lacking
the evidence needed to make a strong case for
There is a close overlap between being person-
centred and rehabilitation. Before discuss it further,
we need to consider two groups of interventions,
those which:
Are effective and applicable across the major-
ity of rehabilitation services;
Are specific to certain conditions.
Interventions – 1
The interventions mentioned most often in reviews
are exercise, education, the giving of information,
and providing psychosocial support. For example, in
cardiac rehabilitation, a recent review identified five
core components of an effective programme.51
Three of the components are applicable to almost all
conditions – exercise training, psychosocial man-
agement, and patient education. Two could be con-
sidered more specific to cardiac disease, nutritional
counselling and risk factor modification, but alterna-
tively they could be considered specific aspects of
patient education. One study suggested psychoso-
cial support was an essential part of respiratory reha-
bilitation,52 but there is little further evidence as to
the meaning or content of ‘psychosocial support’.
Exercise and education will be discussed further.
Exercise, as used in rehabilitation research, carries
two meanings. The first concerns undertaking mus-
cular, physical activities that are associated with
increased energy consumption and cardio-respira-
tory work. The second concerns the performance
of a specified activity, usually practicing it to
improve performance. Often the two will coincide,
with undertaking the task-related practice of walk-
ing being a good example.
The benefits of ‘exercise’ as reported in studies
may therefore arise from:
Practicing a functional activity, by repeatedly
performing it, and
Undertaking more muscular work, increasing
cardio-respiratory work.
There is strong evidence supporting task-ori-
ented and task-specific training after stroke,53 with
6 Clinical Rehabilitation 00(0)
the majority of the benefit being found in improved
performance of the specific task. There is probably
a dose–response relationship,54,55 but in practice,
the extra amount of direct therapy time needed to
make a difference is too large to be feasible.56 The
practice of the activity, rather than direct therapy
input, is probably the main factor leading to bene-
fit. The general principle of task-oriented training
(i.e. practicing a functional activity) applies across
all rehabilitation, because it is a principle underly-
ing learning.
There is also reasonable evidence supporting the
benefits associated with exercise that increases car-
dio-respiratory work. The benefits not only include
better cardio-respiratory function,8–11 but extend
well beyond cardio-respiratory fitness.10,11,39,57
Exercise may help patients with chronic fatigue,58
low back pain,59 osteoarthritis of hip or knee,39
ankle sprains,60 cardiac problems,10 chronic obstruc-
tive pulmonary disease,8 and many more condi-
tions, often ‘with or without education and/or
psychological support’.8
Education and self-management
The specific effect of education is not often studied
separately. One review suggested education
improved quality of life in people with cardiac
However, self-management by a patient with a
long-term disabling condition depends on educa-
tion, and there is evidence to support teaching self-
management strategies for:
Chronic obstructive pulmonary disease,62
improving quality of life, reducing hospital
admissions, but possibly increasing mortality;63
Stroke, improving quality of life;64
Fatigue in people with fatigue associated with
cancer and its treatment.65,66
The common components of successful com-
munity-based programmes67 are also mostly
achieved through education about:
The disease, and management of symptoms
and medication;
Core self-management skills;
Exercise programme;
Self-relaxation training.
In summary, there is good evidence that practic-
ing functional activities and undertaking cardio-
respiratory exercise are both important interventions
in any rehabilitation service. Education is also an
important intervention, although its content is less
well established; it probably always includes
knowledge about the disease; its causes, prognosis,
and treatments; and teaching skills in relation to
self-management. Education may also cover man-
aging the emotional aspects of the illness. Teaching
about prognosis will, importantly, ensure that
the expectations of the patient and family are
Interventions – 2
The range of actions undertaken by a rehabilita-
tion service is dramatically illustrated by the
detailed description of the content of a rehabilita-
tion programme to be undertaken in intensive
care units, being evaluated in a trial. No fewer
than 12 separate components were identified.68
Descriptions of other evaluated rehabilitation
programmes illustrate the number and variety of
actions that constitute a part of the patient’s over-
all rehabilitation.69,70
Thus rehabilitation is definitely a complex inter-
vention, one in which cause–effect relationships
are difficult to establish, are often non-linear, and
often interact (not always beneficially). Table 1
illustrates its complexity of rehabilitation as
assessed using one set of characteristics used to
measure the spectrum of complexity.71
An interesting example of the difficulty in
defining the ‘active ingredient’ comes from a trial
of adding week-end therapy to an inpatient pro-
gramme.72 The trial found a small benefit which, at
first glance, might be attributed to the extra hour of
therapy. However, the associated qualitative
study73 found that ‘The patient-therapist interac-
tion was more important to the patient than the
amount or content of their physiotherapy’. More
importantly, they reported that ‘Saturday therapy
Wade 7
changed patients’ perceptions of weekends in reha-
bilitation’, so that patients in the experimental
group practised more on Sundays too! The effec-
tiveness was probably secondary to a change in the
patient’s perception and expectation (of rehabilita-
tion), not giving extra time.
The complexity of rehabilitation leads to a dif-
ficulty faced by both service providers and com-
missioners. There are very many potential actions
that might benefit a patient, but often there is either
no evidence available about their effectiveness, or
the available evidence is weak or unsupportive.
When evidence of benefit is weak, inconclu-
sive or even negative, it does not necessarily mean
that the intervention should not be used (unless
harm has been demonstrated). First, it may be that
a small number of patients respond well, with the
rest being unaffected, such that benefit cannot be
detected. Second, the intervention may only help
as one component of a bundle of care. Bundles of
Table 1. Complexity of rehabilitation, based on Wells etal.71
n Complexity characteristic Interventions in rehabilitation
1 Number of components within it Multiple components, both in processes and in actions undertaken
2 Its quantity and/or intensity Depends entirely upon the patient’s specific situation and
problem(s); no ‘standard’ dose of any component
3 Ability to specify the components The component processes need to identify and then solve
problems defined, but the actions needed cannot be specified at
the start of rehabilitation
4 Confidence in identification of its
active component
In almost every case, it is impossible to be even partially certain
about the active component, and it is likely that one action
influences several factors within the individual patient’s situation
5 Timing of actions involved Multiple actions over time, with interdependence and often also
dependent upon a correct sequence
6 Number of people involved in its
Usually large, sometimes very large
7 Extent to which responsibility for
intervention can be delineated
Low ability to delineate responsibility, and team members and
others often share responsibility for actions and goals
8 Number of different (professional)
groups involved
Large number of different professional groups involved, often
coming from outside the ‘core team’
9 Technical/professional skill involved Depends upon specialist knowledge and skills in initial assessment
and analysis, in practical treatment processes and in broader
psychological and communication spheres
10 Extent of human interaction needed
to deliver it
Almost totally dependent on human interaction; interpersonal
relationships with the patient, family members, and other involved
professionals are all crucial
11 Number of settings and organizations
May be delivered in many settings consecutively or together
and will almost always involve working across geographic and
organizational boundaries
12 Degree of patient involvement and
participation needed
Patient engagement is essential at all times, with the exception of
patients who are unconscious
13 Sphere of impact of the actions The processes and the effects of actions both involve many
people surrounding the patient
14 Ability to define and measure main
Many important outcomes are difficult to define precisely, and
most are only measurable through patient report. E.g. Quality of
life, life satisfaction, social integration. The patient’s own goals
may not be measurable
8 Clinical Rehabilitation 00(0)
care are common, such as those for reducing
infection74 or errors in surgery.75 Often the indi-
vidual components in a bundle have not been
tested separately.
Conundrum and solution
There is, therefore, a conundrum. Rehabilitation as
a process is beneficial. Some interventions that are
common to all fields of rehabilitation have been
identified. But the evidence base for specific inter-
ventions in any particular group of patients is weak
or absent, with few exceptions.
To resolve this conundrum, the rehabilitation
team must, for each patient::
1. Use a collection of interventions to meet the
patient’s specific needs, taking into account all
aspects of his or her situation, wishes, values,
and so on;
2. Evaluate the patient’s rehabilitation programme
on a planned, ongoing basis using simple tar-
geted measures at appropriate intervals.
That rehabilitation should be so specific to the
patient follows from the trite but vital observation
that every patient is different. In the context of a sin-
gle drug or an operation set within a biomedical
model, these differences may not matter. In rehabili-
tation, which is set within the biopsychosocial model,
it is inevitable that many, if not, most actions need
tailoring to a patient’s situation. Therefore, no two
patients will have exactly the same rehabilitation
package, and no two patients will respond in exactly
the same, predictable way. Consequently, when eval-
uating rehabilitation, each patient needs a tailored
package of assessments to evaluate and alter the
package, the timing of these assessments also being
appropriate to the situation. The process should use a
few simple measures only, often to include checking
for harm (e.g. sedation from a drug used).
One term used to encompass this approach is
person-centred care. This phrase has many mean-
ings. Two reviews illustrate what the phrase
One review76 focused on the values and attitudes
associated with person-centred care, suggesting it
requires an organizational culture with six
Respecting the patient’s perspective;
Being compassionate;
Recognizing the importance of interpersonal
relationships both within the patient’s social
groups and also between the rehabilitation
team and the patient;
Prioritizing a patient’s participation in social
and/or meaningful activities;
Recognizing the patient’s role as a citizen; and
Focusing on a patients strengths and abilities.
A second paper77 focused on the necessary pro-
cesses, identifying eight characteristics:
An individualized set of goals derived from the
patient’s preferences;
Ongoing review of the goals and planned
Use of an interprofessional team (to include the
Identification of a key-worker as a single point
of contact;
Coordination between all people and organiza-
tions involved;
Good communication and sharing of infor-
Education and training of both healthcare staff
and the patient and family; and
Performance measurement and quality-control
using feedback from patients.
The similarities between rehabilitation and
person-centred care is obvious, and there is also
evidence that care described as person-centred is
effective,78,79 but not always.80,81
Finally, this person-centred approach has
already been recognized in one definition of reha-
bilitation, adopted by the American Thoracic
Society (ATS) and the European Respiratory
Society (ERS)4 in 2013:
Pulmonary rehabilitation is a comprehensive
intervention based on a thorough patient assessment
followed by patient-tailored therapies that include,
but are not limited to, exercise training, education,
Wade 9
and behavior change, designed to improve the
physical and psychological condition of people
with chronic respiratory disease and to promote the
long-term adherence to health-enhancing behaviors.
A definition of rehabilitation derived from the evi-
dence reviewed is given in Box 2, and Figure 1 out-
lines the process of rehabilitation that follows from
it. The important features that characterize effec-
tive rehabilitation are as follows:
Basing the process on the biopsychosocial
model of illness;
Having an expert multidisciplinary team, which
uses structured protocols to ensure a consistent,
comprehensive approach.
Undertaking a comprehensive (holistic) initial
(diagnostic) assessment to achieve a full under-
standing of the patient’s situation, both the fac-
tors that influence it and the factors that may
determine interventions;
Using many different interventions tailored to
the particular patient;
Monitoring the changes arising in association
with these interventions, evaluating them
against goals, and checking for potential harms.
Commissioners, organizations responsible for
the quality of a rehabilitation service provided,
and patients considering a rehabilitation service
now have an evidence-based set of criteria to
measure the quality of a service (See also supple-
mentary figure).
Box 2.
An evidence-based description of effective rehabilitation
The goal.
To optimize a patient’s self-rated quality of life and degree of social integration through optimizing independence
in activities, minimizing pain and distress, and optimizing the ability to adapt and respond to changes in
Patients and places:
Rehabilitation may
Benefit anyone with a long-term disabling illness at any stage of that illness;
Be delivered in any setting.
The content.
Is a problem-solving process, framed in the context of the holistic biopsychosocial model of illness,
delivered in a person-centred way, and requiring:
An expert, multidisciplinary team, setting collaborative team-based goals;
○ A formulation of the situation, covering all domains of the biopsychosocial model;
○ Close, collaborative working across all boundaries, professional, organizational, and geographic;
○ Ongoing monitoring of change and effects of interventions.
Will almost always use the following general approaches to management
Repeated practice of functional activities;
General exercise that increases cardio-respiratory work;
Education with an emphasis upon self-management;
Psycho-social support (not well defined yet).
and always involves a large number of specific actions tailored to the patient’s priorities and specific
needs and goals,
Covering (if necessary) all domains of the biopsychosocial model of illness;
Being evaluated regularly for their benefits and harms, to determine whether they should be continued,
changed, or abandoned.
10 Clinical Rehabilitation 00(0)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
Derick T Wade
Supplemental Material
Supplemental material for this article is available online.
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... According to WHO, the core of rehabilitation should be person-centred care that includes empowerment and goal setting [5]. In rehabilitation, goal setting is regarded as an essential aspect and has been defined as the establishment or negotiation of rehabilitation goals and refers to a change and the intended future state of the patient [33][34][35]. In a study where patient-centred goals in dementia care were elicited, participants with dementia articulated the need to readdress goals as the disease progressed. ...
... Interdisciplinary teamwork is recommended for patients with complex problems, as is the case for older adults with dementia [1]. According to Wade 2020, effective rehabilitation depends on a multidisciplinary expert team, working within the biopsychosocial model and working collaboratively toward agreed goals [35]. This is the approach in our rehabilitation programme. ...
... Although the staff had individual strengths, were well educated, or had long working experience they expressed that they needed the others in the team to continuously learn from each other and thereby get a holistic view. This is supported by the statement that there is a need for continuing training in areas outside each person's limited professional field to acquire and maintain specialist expertise [35]. ...
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Background The World Health Organization claims that rehabilitation is important to meet the needs of persons with dementia. Rehabilitation programmes, however, are not routinely available. Person-centred, multidimensional, and interdisciplinary rehabilitation can increase the opportunities for older adults with dementia and their informal primary caregivers to continue to live an active life and participate in society. To our knowledge, staff team experiences of such rehabilitation programmes, involving older adults with dementia and their informal caregivers has not been previously explored. Methods The aim of this qualitative focus group study was to explore the experiences of a comprehensive staff team providing person-centred multidimensional, interdisciplinary rehabilitation to community-dwelling older adults with dementia, including education and support for informal primary caregivers. The 13 staff team members comprised 10 professions who, during a 16-week intervention period, provided individualised interventions while involving the rehabilitation participants. After the rehabilitation period the staff team members were divided in two focus groups who met on three occasions each (in total six focus groups) and discussed their experiences. The Grounded Theory method was used for data collection and analysis. Results The analysis resulted in four categories: Achieving involvement in rehabilitation is challenging, Considering various realities by acting as a link, Offering time and continuity create added value, and Creating a holistic view through knowledge exchange, and the core category: Refining a co-creative process towards making a difference. The core category resembles the collaboration that the staff had within their teams, which included participants with dementia and caregivers, and with the goal that the intervention should make a difference for the participants. This was conducted with flexibility in a collaborative and creative process. Conclusions The staff team perceived that by working in comprehensive teams they could provide individualised rehabilitation in creative collaboration with the participants through interaction, knowledge exchange, time and continuity, coordination and flexibility, and a holistic view. Challenges to overcome were the involvement of the person with dementia in goal setting and the mediating role of the staff team members. The staff pointed out that by refinement they could achieve well-functioning, competence-enhancing and timesaving teamwork.
... It also involves teamwork and a biopsychosocial approach. As a result, it might be difficult to define a core ingredient in rehabilitation, as several aspects and interventions co-exist as different components (Wade, 2020). Effective rehabilitation has been described as a way "to optimize a patient's self-rated quality of life and degree of social integration through optimizing independence in activities, minimizing pain and distress, and optimizing the ability to adapt and respond to changes in circumstances" (Wade, 2020, p. 579). ...
... Further, in a person-centred approach, interventions are to be tailored individually, and different aspects may be of varying importance to different persons. For example, the interaction between the person and the rehabilitation provider might be more important than the amount or content of the interventions (Wade, 2020), implying the importance of the social environment. This was further stressed in a recent mixed methods study that acknowledged good conversation as important in relation to quality improvement in rehabilitation (Sand-Svartrud et al., 2023). ...
... In Sweden, the national guidelines state that the goal of team-based rehabilitation is to restore, as far as is possible, the person's capacity so that she can lead the life she wants (Socialstyrelsen, 2021), which is in line with the previously described definition by Wade (2020). These goals are accomplished through pain relief, improving movements and muscles, or offset impairment. ...
... Stroke is recognized as a major cause of disability worldwide [1] and is often associated with long-term physical, cognitive, social and emotional disabilities [2][3][4], that can result in dependence and reduced participation in everyday life [3,5,6]. To respond to these challenges, priority must be given to person-centred and empowering rehabilitation strategies [7,8]. It is suggested that empowerment can be achieved through person-centred rehabilitation [9,10], provided in collaboration between stroke survivors and health professionals, based on the needs, preferences and goals identified by the stroke survivors and their significant others [7,8]. ...
... To respond to these challenges, priority must be given to person-centred and empowering rehabilitation strategies [7,8]. It is suggested that empowerment can be achieved through person-centred rehabilitation [9,10], provided in collaboration between stroke survivors and health professionals, based on the needs, preferences and goals identified by the stroke survivors and their significant others [7,8]. There are several synonyms for person-centred initiatives, such as clientcentred, user-centred and individual focus [11]. ...
... There are several synonyms for person-centred initiatives, such as clientcentred, user-centred and individual focus [11]. In this study we describe person-centred rehabilitation as initiatives/interventions that supports the individual stroke survivors' and significant others' needs, preferences and goals for the rehabilitation e.g., therapy, interventions, exercises, and knowledge [7,8]. Furthermore, a personcentred rehabilitation should start as early as possible, be coherent (i.e., coordinated with smooth transitions between different rehabilitation settings) and should contain goal setting, intervention/training, support for social participation, discharge support and continuous evaluation [7,12]. ...
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Aim To investigate and describe the process of using experience-based co-design (EBCD) to develop mobile/tablet applications to support a person-centred and empowering stroke rehabilitation. Setting Two cross-sectoral stroke rehabilitation settings in Denmark comprising six rehabilitation units. Participants Stroke survivors (n = 23), significant others (n = 18), occupational therapists (n = 12), physiotherapists (n = 9), representative of a patient organization (n = 1), application developers (n = 3) and researchers (n = 2). Method A structured, facilitated EBCD approach comprising six stages was used to co-design a service that aimed to address the priorities and needs of all relevant end-users. Data were collected by interviews, participant observations, notes on “flip sheets” and written feedback on the content in the apps and on the instruction pages. Data were analyzed descriptively and with a constructivist grounded theory analysis. Results The content in the application solutions “Mit Sygehus” and “Genoptræ” were co-designed to support the needs identified by all end-users. Relevant evidence-based knowledge, person-centred exercises and guidelines using video recordings were the most important among the developed content in the applications to support person-centred and empowering stroke rehabilitation. Furthermore, easy, and seamless communication were considered important. Conclusions EBCD facilitated the development of content in the applications to support a person-centred and empowering stroke rehabilitation. Participants experienced that their contribution was considered important and valued.
... The concept of goal setting has been considered integral to rehabilitation and behavioural change interventions (Wade, 2020). As Wade (2009) argues elsewhere, "a goal is the intended outcome of a specific set of interventions" and therefore it seems obvious that goal setting would form an essential part of effective musculoskeletal care. ...
Full-text available
Introduction: Goal setting is a key part of rehabilitation across various fields of physiotherapy. It is less clear what evidence exists to underpin its effectiveness and to practically guide its use within musculoskeletal physiotherapy. Objectives: This scoping review provides an overview of current research regarding goal setting in adult physiotherapy-led musculoskeletal care with three aims: 1) to identify and analyse any gaps in the literature, 2) to identify relevant features of goal setting theory and 3) to make recommendations for future research. The principal research question was what does the literature tell us about the role of goal setting for adults over the age of 18 with musculoskeletal pain accessing outpatient physiotherapy services? Inclusion criteria: The population, concept and context framework was used to define the inclusion criteria. Key definitions were adults over the age of 18 with musculoskeletal conditions, goal setting, and physiotherapy-led interventions. Methods: This scoping review followed the guidance set out by the Joanna Briggs Institute Manual for Evidence Synthesis. Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, MEDLINE, American Psychological Association PsycInfo and the Cochrane Database of Systematic Reviews, Protocols and Trials were searched using pre-defined search criteria. Data were extracted from screened full-text articles and presented in basic statistical and narrative form. Results: 41 articles were included in the review. Several broad themes and research methods were identified. The nature of the studies suggested that the clinical application of goal setting is complex and the depth of understanding is limited. Most studies suggested that goal setting is feasible and has a positive impact on outcomes. A common finding was a lack of clear definitions regarding goal setting terminology and approaches. Study samples were generally defined by biomedical categories, suggesting a pathoanatomical approach to researching a cognitive construct. Theoretical underpinning was lacking in many studies. No frameworks guiding goal setting in physiotherapy-led musculoskeletal rehabilitation have been identified. Conclusions: Goal setting is a popular tool within musculoskeletal outpatient physiotherapy. Further research is required to clarify its efficacy and provide guidance on its role and application in clinical practice.
Successful walking is a substantial contributor to quality of life in people with lower-limb amputation (PLLA), yet gait difficulties are common. Evidence-based exercise guidelines are necessary for PLLA with different clinical characteristics and at different phases of recovery. To systematically review the literature evaluating effects of exercise interventions on gait outcomes in PLLA at subacute and chronic stages of recovery. Databases MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, and the Cochrane Library were searched (inception to May 10, 2022). Inclusion criteria: randomized controlled trials assessing gait outcomes following exercise intervention; subjects were PLLA ≥18 years of age and used a prosthesis for walking. Meta-analysis using random effects with inverse variance to generate standardized mean differences (SMDs) was completed for primary gait outcomes. Subgroup analysis was conducted for the recovery phase (i.e., subacute and chronic) and level of amputation (e.g., transfemoral and transtibial). Of 16 included articles, 4 studies examined the subacute phase of recovery, whereas 12 examined the chronic phase. Subacute interventions were 30 minutes, 1-7 times/week, for 2-12 weeks. Chronic interventions were 15-60-minutes, 2-3 times/week, for 4-16 weeks. Low-moderate level evidence was shown for a small improvement in the subacute phase (SMD = 0.42, 95% confidence interval [0.06-0.79], I2 = 46.0%) and a moderate improvement in the chronic phase (SMD = 0.67, 95% confidence interval [0.40-0.94], I2 = 0.0%) in favor of exercise intervention groups. Multicomponent exercise programs consisting of gait, balance, and strength training are effective at improving gait outcomes in PLLA at subacute and chronic phases of recovery. The optimal duration and frequency of exercise is unclear because of variation between interventions, highlighting an area for future work.
Interprofessional practice is increasingly cited as necessary in the delivery of high-quality nutrition and rehabilitation services. However, there is limited evidence available exploring the factors which influence interprofessional practice in subacute rehabilitation nutrition services. Our ethnographic study explored collaborative activities, influential factors and staff attitudes related to interprofessional practice in nutrition care. Fifty-eight hours of ethnographic field work were undertaken from September 2021-April 2022, across three subacute rehabilitation units, with a total of 165 patients, support persons and staff participating. Overall, 125 unique participants were observed and 77 were interviewed. We generated three themes through reflexive thematic analysis. First, the potential opportunities for interprofessional practice at mealtimes, as influenced by communication, role clarity and reciprocity. Second, hierarchy of nutrition roles and tasks impedes interprofessional practice, where the perceived lower importance of nutrition care to other clinical roles and physical therapies influences staff practice. Third, the mystery of nutrition care roles and systems in rehabilitation, which exposes gaps in the awareness of different team members regarding nutrition care roles and systems, hindering interprofessional practice. Our findings highlight the opportunity for embedded, innovative models of care and staff education to enhance interprofessional practice in nutrition and mealtimes.
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Introduction: Differences in care pathways/the delivery of rehabilitation care for young people with acquired brain injury (ABI) across rehabilitation centers (RCs), may lead to unwanted practice variations. Objective: Identifying potential similarities/differences regarding the care structure across RCs. Methods: In this cross-sectional study, Healthcare professionals from Dutch RCs that work with young people(<25 years) with ABI were invited to complete a 21-item questionnaire (12 yes/no& nine corresponding open-ended-questions). Questions were divided into three topics: admission/discharge criteria (n=2&2), organization of rehabilitation (n=7&5), and aftercare (n=3&2). Answers to open-ended questions were thematically analyzed/categorized. Differences across RCs were defined as an item being present/described in <75% of the RCs. Results: Rehabilitation professionals from 12 RCs participated. Similarities and differences were found regarding the structure of rehabilitation care. Concerning admission criteria(present in all RCs), “an ABI diagnosis” was seen by all RCs as an essential criterium, whereas all other admission criteria were described differently. The discharge criterium "goal-attainment" was the only criterium found in ≥75% of the RCs. Regarding the organization of rehabilitation, most RCs (≥75%) described “the presence of specialized teams”&“diagnosis-specific consultation appointments”. Differences were found, e.g., the “presence of transition-teams” for young adults (<75%). Concerning aftercare, similarities were found in the “presence of structural end-reports”&“discharge/follow-up appointments”. However, differences were seen in the “timing between discharge&follow-up”. Conclusion: Besides similarities between RCs, differences were found regarding the structure of outpatient rehabilitation. Gaining insights into differences across RCs and reducing practice variation could reinforce collaborations between RCs to harmonize/optimize care quality for young people with ABI.
Background Young adult cancer survivors (YACS) aged 18–39 report age-specific multifactorial challenges with self-care, leisure, work and education requiring multicomponent rehabilitation intervention. Therefore, the ‘Young Adult Taking Action’ (YATAC) programme was developed. Aims/Objectives To present a protocol for a feasibility study evaluating the acceptability of the YATAC programme and exploring implementation, mechanisms of impact and outcomes. Material and methods A mixed-method feasibility study with a convergent research design will be conducted. The programme is an age-specific, multicomponent, goal-oriented, and peer-based rehabilitation programme delivered by an interdisciplinary staff consisting of nine components: 1) Goal setting, 2) Everyday life, 3) Physical activity, 4) Psychological issues, 5) Work and study, 6) Sexuality and relationship, 7) Rights and finance, 8) Peer-to-peer support and 9) Individual consultation. Quantitative and qualitative data about acceptability, implementation, mechanisms of impact and outcomes will be collected. Results The results will provide essential knowledge about the programme’s acceptability, implementation, mechanisms of impact and outcomes. Conclusion and significance The study will inform adjustment of the programme and will provide knowledge of whether and how to deliver age-specific rehabilitation to YACS.
Introduction: Doctors working in rehabilitation settings have specialized clinical skills and experience, but research activity may be constrained by time pressures and inadequate current skills. This means missed opportunities to contribute to the evidence-base for better clinical practice and outcomes for people living with disabling, chronic complex conditions. This research aimed to understand rehabilitation doctors' research needs, experience, and aspirations to enable future training initiatives that are tailored to their practice context. Methods: This exploratory sequential mixed-method study comprised a survey followed by focus groups. Rehabilitation doctors from three health services in south-east Queensland, Australia completed an online survey incorporating the Research Spider to explore their research experience, confidence, interest, opportunity, and intent. Focus groups explored the survey results and participants' views regarding strategies to build research capacity. Results: The major findings were the gap between high research interest and low experience, confidence and opportunity; and fundamental research skills were identified as priority training topics. These findings support previous research. However, rehabilitation doctors may also have a self-expectation that, as competent clinicians, they should necessarily also be research-competent, and hold misperceptions regarding the shared nature of health services research. Discussion: Protected time and funding may enhance engagement with research to generate specialty-relevant evidence for practice. To this end, a research capacity building initiative in the form of a series of self-directed learning packages has been developed and implemented. A tailored workshop to strengthen rehabilitation doctors' research skills and engagement has also been developed for implementation.
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Background Inpatient multidisciplinary rehabilitation (MDR) can improve health-related quality of life (HRQoL) in multiple sclerosis (MS) patients. However, the evidence of a long-term benefit is limited. Objectives To investigate the long-term effectiveness of inpatient MDR on HRQoL in MS patients. Methods We conducted a randomized controlled partial crossover trial with 427 MS patients. Results Statistical significant long-term improvements in HRQoL were found in three of the six outcome measures at 12-month follow-up. Three in four suggested minimal clinically important differences (MCIDs) were unmet. Conclusion These results indicate that the administration of inpatient MDR may lead to long-lasting improvements in HRQoL in MS patients.
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Background: Breast cancer (BC) is the most common type of cancer in women worldwide. Post-treatment, patients suffer from side effects and have various rehabilitation needs, which means that individualization is fundamental for optimal rehabilitation. This systematic review (SR) of SRs aims to evaluate the current evidence on rehabilitation interventions in female patients following BC treatment. Methods: Full-text SRs published in English from 2009 were searched in Embase, PubMed, Cinahl Complete, PsycINFO, AMED, SCOPUS, and Cochrane Library. Inclusion criteria: SRs of randomized or non-randomized controlled trials investigating the effects of rehabilitation interventions in women following BC treatment. All outcomes were considered. Methodological quality was evaluated using the AMSTAR 2 tool and interrater agreement was evaluated. Out of 1269 citations retrieved, 37 SRs were included. Results: Five rehabilitation areas were identified: exercise and physical activity (PA), complementary and alternative medicine (CAM), yoga, lymphoedema treatment, and psychosocial interventions. The most solid evidence was found in exercise/PA and yoga. Exercise interventions improved outcomes such as shoulder mobility, lymphoedema, pain, fatigue and quality of life (QoL). Effects of yoga were shown on QoL, anxiety, depression, sleep disturbance, fatigue and gastrointestinal symptoms. The effect of CAM was shown on nausea, pain, fatigue, anger and anxiety but these results need to be interpreted with caution because of low methodological quality in included studies in the SRs. Among the lymphoedema treatments, positive effects were seen for resistance training on volume reduction and muscle strength and psychosocial interventions such as cognitive behavioural therapy had positive effects on QoL, anxiety, depression and mood disturbance. Conclusions: This SR of SRs show solid positive effects of exercise/PA and yoga for women following BC treatment, and provides extended knowledge of the effects of CAM, yoga, lymphoedema treatment and psychosocial interventions. It is evident that more than one intervention could have positive effects on a specific symptom and that the effects depend not only on intervention type but also on how and when the intervention is provided. The results can be used as a foundation for individualized rehabilitation and aid health care professionals in meeting patients' individual needs and preferences. Trial registration: PROSPERO ( CRD42017060912 ).
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Background:: Many patients with moderate to severe traumatic brain injury have deficits in social cognition. Social cognition refers to the ability to perceive, interpret, and act upon social information. Few studies have investigated the effectiveness of treatment for impairments of social cognition in patients with traumatic brain injury. Moreover, these studies have targeted only a single aspect of the problem. They all reported improvements, but evidence for transfer of learned skills to daily life was scarce. We evaluated a multifaceted treatment protocol for poor social cognition and emotion regulation impairments (called T-ScEmo) in patients with traumatic brain injury and found evidence for transfer to participation and quality of life. Purpose:: In the current paper, we describe the theoretical underpinning, the design, and the content of our treatment of social cognition and emotion regulation (T-ScEmo). Theory into practice:: The multifaceted treatment that we describe is aimed at improving social cognition, regulation of social behavior and participation in everyday life. Some of the methods taught were already evidence-based and derived from existing studies. They were combined, modified, or extended with newly developed material. Protocol design:: T-ScEmo consists of 20 one-hour individual sessions and incorporates three modules: (1) emotion perception, (2) perspective taking and theory of mind, and (3) regulation of social behavior. It includes goal-setting, psycho-education, function training, compensatory strategy training, self-monitoring, role-play with participation of a significant other, and homework assignments. Recommendations:: It is strongly recommended to offer all three modules, as they build upon each other. However, therapists can vary the time spent per module, in line with the patients' individual needs and goals. In future, development of e-learning modules and virtual reality sessions might shorten the treatment.
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A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane’s tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54–0.85) and ET (HR = 0.75, 95% CrI = 0.60–0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57–0.99), ET (HR = 0.75, 95% CrI = 0.56–0.99) and PE (HR = 0.68, 95% CrI = 0.47–0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58–0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.
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Objectives: To determine if exercise-based rehabilitation reduces reinjury following acute ankle sprain. Our secondary objective was to assess if rehabilitation efficacy varies according to exercise content and training volume. Data sources: The following electronic databases were searched: EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro). Study selection: Randomized controlled trials investigating the effect of exercise-based rehabilitation programs on reinjury and patient-reported outcomes (perceived instability, function, pain) in people with an acute ankle sprain. No restrictions were made on the exercise type, duration, or frequency. Exercise-based programs could have been administered in isolation or as an adjunct to usual care. Comparisons were made to usual care consisting of 1 or all components of PRICE (protection, rest, ice, compression, elevation). Data extraction: Effect sizes with 95% CIs were calculated in the form of mean differences for continuous outcomes and odds ratios (ORs) for dichotomous outcomes. Pooled effects were calculated for reinjury prevalence with meta-analysis undertaken using RevMan software. Data synthesis: Seven trials (n=1417) were included (median PEDro score, 8/10). Pooled data found trends toward a reduction in reinjury in favor of the exercise-based rehabilitation compared with usual care at 3-6 months (OR, 0.87; 95% CI, 0.48-1.58) with significant reductions reported at 7-12 months (OR, 0.53; 95% CI, 0.38-0.73). Sensitivity analysis based on pooled reinjury data from 2 high quality studies (n=629) also found effects in favor of exercise-based rehabilitation at 12 months (OR, 0.60; 95% CI, 0.49-0.89). Training volume differed substantially across rehabilitation programs with total rehabilitation time ranging from 3.5-21 hours. The majority of rehabilitation programs focused primarily on postural balance or strength training. Conclusions: Exercise-based rehabilitation reduces the risk of reinjury following acute ankle sprain when compared with usual care alone. There is no consensus on optimal exercise content and training volume in this field. Future research must explicitly report all details of administered exercise-based rehabilitation programs.
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[Purpose] To review the literature that examines rehabilitation and early mobilization and that involves different practices (effects of interventions) for the critically ill patient. [Materials and Methods] A PRISMA-Systematic review has been conducted based on different data sources: Biblioteca Virtual en Salud, CINHAL, Pubmed, Scopus, and Web of Science were used to identify randomized controlled trials, crossover trials, and case-control studies. [Results] Eleven studies were included. Early rehabilitation had no significant effect on the length of stay and number of cases of Intensive Care Unit Acquired Weaknesses. However, early rehabilitation had a significant effect on the functional status, muscle strength, mechanical ventilation duration, walking ability at discharge, and health quality of life. [Conclusion] Rehabilitation and early mobilization are associated with an increased probability of walking more distance at discharge. Early rehabilitation is associated with an increase in functional capacity and muscle strength, an improvement in walking distance and better perception of the health-related quality of life. Cycloergometer and electrical stimulation can be used to maintain muscle strength. Further research is needed to establish stronger evidences.
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Introdução A Doença de Alzheimer (DA) é caracterizada por perda das funções cognitivas de forma progressiva, como falhas na memória, aprendizagem e linguagem, que tendem a se agravar com o avanço da doença. As ações multidisciplinares no paciente com DA têm como objetivo interferir positivamente no processo saúde-doença, por meio de uma abordagem integral aos indivíduos e familiares, intervindo com ações voltadas à realidade na qual estão inseridos. Objetivo Realizar uma revisão sistemática sobre os efeitos da reabilitação multidisciplinar em pacientes com Doença de Alzheimer (DA). Método Foram realizadas buscas nas bases MEDLINE, LILACS, PEDro, CINAHL e Web of Science , sem restrição de data ou de idioma de publicação. Os artigos foram avaliados pelo título, pelo resumo e, posteriormente, pelo texto completo, por dois autores independentes. A qualidade metodológica dos estudos experimentais selecionados foi avaliada de acordo com a escala PEDro. Resultados Foram incluídos cinco estudos, de qualidade metodológica moderada (5,4 na escala PEDro), que evidenciaram que um programa multidisciplinar pode ser eficaz no tratamento de pacientes com DA, com melhoras significativas, principalmente, em sintomas neuropsiquiátricos, depressão e qualidade de vida. Para as demais medidas de desfecho investigadas, devido à presença de poucos estudos que encontraram efeitos positivos (nível de estresse, ansiedade, independência, atividades) ou de resultados conflitantes (cognição), não é possível determinar a eficácia dessa intervenção. Conclusão Esta revisão sistemática evidenciou que um programa multidisciplinar pode ser eficaz no tratamento de pacientes com DA, com melhoras significativas, principalmente, em sintomas neuropsiquiátricos, depressão e qualidade de vida. No entanto, os resultados para cognição, nível de ansiedade, estresse, independência e realização de atividades não foram significativos ou foram conflitantes.
Objective To systematically investigate how fatigue, depression, anxiety, sleep quality, and life quality are influenced by the Internet-based self-management program (IBSMP) among cancer patients. Data sources Eight databases (Cochrane Library, Ovid, Web of Science, Medline, Embase, Chinese biomedical database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang) were systematically searched from inception to January 2019. Methods The aim of this study is to identify randomized controlled trials (RCTs) associated with the IBSMP among cancer-related fatigue (CRF) patients. Two reviewers independently screened 1128 records and selected 13 articles, including 1603 patients for inclusion. The quality of the evidence was assessed at the study level and at the outcome level. Results The meta-analysis showed that the IBSMP was effective for ameliorating fatigue and related symptoms among cancer survivors (the Brief Fatigue Index, relative risk = 0.74, 95% confidence interval (CI; 0.69, 0.79), P < 0.01; the Cancer Fatigue Scale or the Multidimension Fatigue Scale, weighted mean difference = −10.15, 95% CI (−11.42, −8.89), P < 0.01; the Self-rating Anxiety scale, relative risk = 1.07, 95% CI (0.55, 2.05), P < 0.01; the Self-rating Depression scale, relative risk = 0.70, 95% CI (0.60, 0.81), P < 0.01; the Pittsburgh Sleep Quality Index, relative risk = 0.46, 95% CI (0.33, 0.62), P < 0.01; and the Function Assessment of Cancer Therapy—General scale or the Function Assessment of Cancer Therapy—Breast, weighted mean difference = 13.76, 95% CI (3.38, 24.14), P < 0.01.) Conclusion This meta-analysis demonstrates that the IBSMP, as one of the rehabilitation forms, can reduce the incidence of fatigue, depression, and anxiety and improve sleep quality and life quality among CRF patients.
Background: Health services for individuals with chronic conditions often include a disease specific community rehabilitation programme to assist these individuals to maintain physical function and develop self-management skills. Nurses are often involved in the delivery of such programmes. Many individuals however live with more than one chronic condition and find it difficult to manage the rehabilitation demands for their different diagnoses. Objective: To identify core programme components and clinically meaningful measures for a generic rehabilitation programme. Data sources: Full text English language journal articles identified from CINAHL, MEDLINE (Ovid), AMED and PubMed, plus reference lists of included articles. Review method: A systematic search of databases using keywords and MeSH terms for randomised controlled trials detailing a group based community programme for adults with chronic conditions. Study quality was appraised using the Cochrane Collaboration Tool for assessing risk of bias for randomised controlled trials. Data summarising characteristics of the studies such as participant numbers, programme components and the questionnaires, scales and measures were extracted and tabulated. An additional search of wider literature was undertaken to identify the minimal clinically important difference for each questionnaire, scale or measure used within the included studies. Results: Fifteen good quality studies were identified. At baseline, there were 3856 participants (age range 42-84 years), with 642 participants lost to follow-up. Programmes were led by health professionals and/or lay leaders. Programme duration ranged from four to 12 weeks and included educational components targeting symptom management, and development of self-efficacy. Only three programmes included a supervised exercise component. Although many of the 64 outcomes measured across the programmes demonstrated statistically significant results, only three measures demonstrated clinically meaningful change for study participants and these measures were used in only two studies. Conclusions and recommendations: The findings suggest community rehabilitation programmes for individuals with chronic conditions be a minimum of 4-6 weeks to cover necessary education for management of symptoms, be led by a health professional/s in combination with lay leaders, and include development of self-management skills. We recommend consideration be given to health literacy level of the programme, and that because of the known positive benefit of exercise on physical functioning, quality of life and in slowing progression of chronic conditions, an exercise time should be included. Lastly, we recommend that reporting and interpreting effect sizes of interventions within studies would facilitate more useful choice of outcome measures to be able to demonstrate clinically meaningful change.
Background: Multiple sclerosis (MS) is a major cause of chronic, neurological disability, with a significant long-term disability burden, often requiring comprehensive rehabilitation. Objectives: To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge. Methods: We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) tool, and the quality of the evidence for reported outcomes, using the GRADE framework. Main results: Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R-AMSTAR criteria.Moderate-quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge. Low-qualitty evidence suggested that neuropsychological interventions, symptom-management programmes (spasticity), whole body vibration, and telerehabilitation improved some patient outcomes. Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies. Authors' conclusions: The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit, although the certainty of evidence varies across the different types of interventions evaluated by the reviews. Structured, multidisciplinary rehabilitation programmes and physical therapy (exercise or physical activities) can improve functional outcomes (mobility, muscle strength, aerobic capacity), and quality of life. Overall, the evidence for many rehabilitation interventions should be interpreted cautiously, as the majority of included reviews did not include data from current studies. More studies, with appropriate design, which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge.