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Clinical Rehabilitation
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CLINICAL
REHABILITATION
What is rehabilitation? An
empirical investigation leading
to an evidence-based description
Derick T Wade
Abstract
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.
Keywords
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.
Email: derick.wade@ntlworld.com;
Twitter: @derickwaderehab
905112CRE0010.1177/0269215520905112Clinical RehabilitationWade
research-article2020
Editorial
2 Clinical Rehabilitation 00(0)
Introduction
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
matter?
Process: what are the common features of the
process?
Interventions: what interventions are used?
It develops an evidence-based description of
effective rehabilitation.
Context
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
benefit?
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
Malignancies.23,24
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
disorder.
Is rehabilitation effective anywhere?
Rehabilitation has been found effective in most
settings:
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
effective.32,35
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
effectiveness?
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
following:
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
disease.40,41
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
cancer.42
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.
Process
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
illness
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
paediatrics.
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
following:
Communication;
Coordination;
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-
centred)
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
them.48–50
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
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
disease.61
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
appropriate.
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 etal.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
delivery
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
involved
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
outcome(s)
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
encompasses.
One review76 focused on the values and attitudes
associated with person-centred care, suggesting it
requires an organizational culture with six
characteristics:
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
actions;
Use of an interprofessional team (to include the
patient);
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-
mation;
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.
Conclusion
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
circumstances.
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.
Rehabilitation:
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.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Derick T Wade https://orcid.org/0000-0002-1188
-8442
Supplemental Material
Supplemental material for this article is available online.
References
1. NHS England. Commissioning guidance for rehabilita-
tion. Publications Gateway reference no: 04919, https://
www.england.nhs.uk/wp-content/uploads/2016/04/
Figure 1. Rehabilitation: who benefits, what structures are needed, what processes occur, and what is the
outcome?
rehabilitation-comms-guid-16-17.pdf (accessed 2
December 2019).
2. Wade DT and De Jong B. Recent advances in rehabilita-
tion. BMJ 2000; 320: 1355–1358.
3. Wade DT. Rehabilitation – a new approach: part four: a
new paradigm, and its implications. Clin Rehabil 2016;
30(2): 109–118.
4. Spruit MA, Singh SJ, Garvey C, et al. An Official
American Thoracic Society/European Respiratory Society
Statement: key concepts and advances in pulmonary
rehabilitation. Am J Respir Crit Care Med 2013; 188(8):
e13–e64.
5. Langhorne P and Pollock A. What are the components
of effective stroke unit care? Age Ageing 2002; 31(5):
365–371.
6. Stroke Unit Trialists’ Collaboration. Organised inpatient
(stroke unit) care for stroke. Cochrane Database Syst Rev
2013; 9: CD000197.
7. Puhan MA, Gimeno-Santos E, Cates CJ, et al. Pulmonary reha-
bilitation following exacerbations of chronic obstructive
pulmonary disease. Cochrane Database Syst Rev 2016; 12:
CD005305.
8. McCarthy B, Casey D, Devane D, et al. Pulmonary reha-
bilitation for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev 2015; 2: CD003793.
Wade 11
9. Dowman L, Hill CJ and Holland AE. Pulmonary reha-
bilitation for interstitial lung disease. Cochrane Database
Syst Rev 2014; 10: CD006322.
10. Anderson L and Taylor RS. Cardiac rehabilitation for
people with heart disease: an overview of Cochrane sys-
tematic reviews. Cochrane Database Syst Rev 2014; 12:
CD011273.
11. Shields GE, Wells A, Doherty P, et al. Cost-effectiveness
of cardiac rehabilitation: a systematic review. Heart 2018;
104: 1403–1410.
12. Amatya B, Khan F and Galea M. Rehabilitation for people
with multiple sclerosis: an overview of Cochrane Reviews.
Cochrane Database Syst Rev 2019; 1: CD012732.
13. Boesen F, Norgaard M, Skjerbaek AG, et al. Can inpa-
tient multidisciplinary rehabilitation improve health-
related quality of life in MS patients on the long term
– The Danish MS Hospitals Rehabilitation Study. Mult
Scler. Epub ahead of print 5 November 2019. DOI:
10.1177/1352458519884244.
14. Boesen F, Norgaard M, Trenel P, et al. Longer term effec-
tiveness of inpatient multidisciplinary rehabilitation on
health-related quality of life in MS patients: a pragmatic
randomized controlled trial – The Danish MS Hospitals
Rehabilitation Study. Mult Scler 2018; 24(3): 340–349.
15. Rooney J, Byrne S, Heverin M, et al. A multidisciplinary
clinic approach improves survival in ALS: a comparative
study of ALS in Ireland and Northern Ireland. J Neurol
Neurosurg Psychiatry 2015; 86(5): 496–501.
16. Turner-Stokes L, Pick A, Nair A, et al. Multi-disciplinary
rehabilitation for acquired brain injury in adults of working
age. Cochrane Database Syst Rev 2015; 12: CD004170.
17. Ferrazzoli D, Ortelli P, Zivi I, et al. Efficacy of inten-
sive multidisciplinary rehabilitation in Parkinson’s dis-
ease: a randomised controlled study. J Neurol Neurosurg
Psychiatry 2018; 89(8): 828–835.
18. Nordstrom P, Thorngren KG, Hommel A, et al. Effects
of geriatric team rehabilitation after hip fracture: meta-
analysis of randomized controlled trials. J Am Med Dir
Assoc 2018; 19(10): 840–845.
19. Handoll HHG, Cameron ID, Mak JCS, et al. Multi-
disciplinary rehabilitation for older people with hip frac-
tures. Cochrane Database Syst Rev 2009; 4: CD007125.
20. Khan F, Ng L, Gonzalez S, et al. Multidisciplinary reha-
bilitation programmes following joint replacement at the
hip and knee in chronic arthropathy. Cochrane Database
Syst Rev 2008; 2: CD004957.
21. Kamper SJ, Apeldoorn AT, Chiarotto A, et al.
Multidisciplinary biopsychosocial rehabilitation for
chronic low back pain. Cochrane Database Syst Rev
2014; 9: CD000963.
22. Marin TJ, Van Eerd D, Irvin E, et al. Multidisciplinary
biopsychosocial rehabilitation for subacute low back pain.
Cochrane Database Syst Rev 2017; 6: CD002193.
23. Olsson Moller U, Beck I, Ryden L, et al. A comprehensive
approach to rehabilitation interventions following breast
cancer treatment – a systematic review of systematic
reviews. BMC Cancer 2019; 19(1): 472.
24. Scott DA, Mills M, Black A, et al. Multidimensional
rehabilitation programmes for adult cancer survivors.
Cochrane Database Syst Rev 2013; 3: CD007730.
25. Tipping CJ, Harrold M, Holland A, et al. The effects of
active mobilisation and rehabilitation in ICU on mortal-
ity and function: a systematic review. Intensive Care Med
2017; 43(2): 171–183.
26. Arias-Fernandez P, Romero-Martin M, Gomez-Salgado J,
et al. Rehabilitation and early mobilization in the critical
patient: systematic review. J Phys Ther Sci 2018; 30(9):
1193–1201.
27. Fuke R, Hifumi T, Kondo Y, et al. Early rehabilitation
to prevent post-intensive care syndrome in patients with
critical illness: a systematic review and meta-analysis.
BMJ Open 2018; 8: e019998, https://bmjopen.bmj.com/
content/8/5/e019998
28. Doiron KA, Hoffmann TC and Beller EM. Early inter-
vention (mobilization or active exercise) for critically ill
adults in the intensive care unit. Cochrane Database Syst
Rev 2018; 3: CD010754.
29. Doig E, Fleming J, Kuipers P, et al. Comparison of reha-
bilitation outcomes in day hospital and home settings for
people with acquired brain injury – a systematic review.
Disabil Rehabil 2010; 32(25): 2061–2077.
30. Forster A, Young J and Langhorne P. Systematic review
of day hospital care for elderly people. BMJ 1999;
318(7187): 837–841.
31. Crocker T, Forster A, Young J, et al. Physical reha-
bilitation for older people in long-term care. Cochrane
Database Syst Rev 2013; 2: CD004294.
32. Langhorne P and Baylan S. Early supported discharge
services for people with acute stroke. Cochrane Database
Syst Rev 2017; 7: CD000443.
33. Blair J, Corrigall H, Angus N, et al. Home versus hospital-
based cardiac rehabilitation: a systematic review. Rural
Remote Health 2011; 11(2): 1532, https://www.rrh.org.
au/journal/article/1532/
34. Hillier S and Inglis-Jassiem G. Rehabilitation for commu-
nity-dwelling people with stroke: home or centre based? A
systematic review. Int J Stroke 2010; 5: 178–186.
35. Verweij L, van de Korput E, Daams JG, et al. Effects of
postacute multidisciplinary rehabilitation including exer-
cise in out-of-hospital settings in the aged: systematic
review and meta-analysis. Arch Phys Med Rehabil 2019;
100(3): 530–550.
36. Donovan WH. Spinal cord injury – past, present, and
future. J Spinal Cord Med 2007; 30: 85–100.
37. Silver JR. History of the treatment of spinal injuries.
Postgrad Med J 2005; 81(952): 108–114.
38. Bunketorp-Käll L, Lundgren-Nilsson Å, Samuelsson H,
et al. Long-term improvements after multimodal reha-
bilitation in late phase after stroke. Stroke 2017; 48:
1916–1924.
39. Hurley M, Dickson K, Hallett R, et al. Exercise inter-
ventions and patient beliefs for people with hip, knee
or hip and knee osteoarthritis: a mixed methods review.
Cochrane Database Syst Rev 2018; 4: CD010842.
12 Clinical Rehabilitation 00(0)
40. Madureira BG, Pereira MG, Avelino PR, et al. Efeitos de
programas de reabilitação multidisciplinar no tratamento de
pacientes com doença de Alzheimer: uma revisão sistemática.
[Effects of multidisciplinary rehabilitation programs on
treatment of patients with Alzheimer’s disease: a system-
atic review]. Cad Saúde Colet 2018; 26: 222–232, http://
www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-
462X2018000200222
41. Sá CDC, Silva DFD, Bigongiari A, et al. Eficácia da
reabilitação cognitiva na melhoria e manutenção das
atividades de vida diária em pacientes com doença de
Alzheimer: uma revisão sistemática da literatura [Efficacy
of cognitive rehabilitation in improving and maintaining
daily living activities in patients with Alzheimer’s disease:
a systematic review of literature]. J Bras Psiquiatr 2019;
68: 153–160, http://www.scielo.br/scielo.php?script=sci_
arttext&pid=S0047-20852019000300153
42. Salakari MRJ, Surakka T, Nurminen R, et al. Effects of
rehabilitation among patients with advances cancer: a sys-
tematic review. Acta Oncol 2015; 54(5): 618–628.
43. Wade DT and Halligan PW. The biopsychosocial model
of illness: a model whose time has come. Clin Rehabil
2017; 31(8): 995–1004.
44. Wade DT. A teamwork approach to neurological rehabili-
tation. In: Dietz V and Ward NS (eds) Oxford textbook of
neurorehabilitation. 2nd ed. Oxford: Oxford University
Press, 2020, pp. 9–21.
45. Choi BCK and Pak AP. Multidisciplinary, interdiscipli-
nary, and transdisciplinary in health research, services,
education, and policy: 1. Definitions, objectives, and evi-
dence of effectiveness. Clin Invest Med 2006; 29: 351–364.
46. Strasser DC, Falconer JA, Herrin JS, et al. Team func-
tioning and patient outcomes in stroke rehabilitation. Arch
Phys Med Rehabil 2005; 86(3): 403–409.
47. Tyson SF, Burton L and McGovern A. The effect of a
structured model for stroke rehabilitation multi-discipli-
nary team meetings on functional recovery and productiv-
ity: a phase I/II proof of concept study. Clin Rehabil 2015;
29(9): 920–925.
48. Levack WMM, Weatherall M, Hay-Smith EJC, et al. Goal
setting and strategies to enhance goal pursuit for adults
with acquired disability participating in rehabilitation.
Cochrane Database Syst Rev 2015; 7: CD009727.
49. Shay LA and Lafata JE. Where is the evidence? A sys-
tematic review of shared decision making and patient out-
comes. Med Decis Making 2015; 35(1): 114–131.
50. Rose A, Rosewilliam S and Soundy A. Shared decision
making within goal setting in rehabilitation settings: a sys-
tematic review. Patient Educ Couns 2017; 100(1): 65–75.
51. Kabboul NN, Tomlinson G, Francis TA, et al.
Comparative effectiveness of the core components of car-
diac rehabilitation on mortality and morbidity: a system-
atic review and network meta-analysis. J Clin Med 2018;
7(12): E514, https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6306907/
52. Lacasse Y, Guyatt GH and Goldstein RS. The components
of a respiratory rehabilitation program: a systematic over-
view. Chest 1997; 111(4): 1077–1088.
53. Veerbeek JM, van Wegen E, van Peppen R, et al. What is
the evidence for physical therapy poststroke? A systematic
review and meta-analysis. PLoS ONE 2014; 9(2): e87987,
https://journals.plos.org/plosone/article?id=10.1371/jour-
nal.pone.0087987
54. Veerbeek JM, Koolstra M, Ket JC, et al. Effects of aug-
mented exercise therapy on outcome of gait and gait-
related activities in the first 6 months after stroke. Stroke
2011; 42(11): 3311–3315.
55. Lohse KR, Lang CE and Boyd LA. Is more better? Using
metadata to explore dose–response relationships in stroke
rehabilitation. Stroke 2014; 45(7): 2053–2058.
56. Schneider EJ, Lannin NA, Ada L, et al. Increasing the
amount of usual rehabilitation improves activity after stroke:
a systematic review. J Physiother 2016; 62(4): 182–187.
57. Anderson L, Thompson DR, Oldridge N, et al. Exercise-
based cardiac rehabilitation for coronary heart disease.
Cochrane Database Syst Rev 2016; 1: CD001800.
58. Larun L, Brurberg KG, Odgaard-Jensen J, et al. Exercise
therapy for chronic fatigue syndrome. Cochrane Database
Syst Rev 2017; 4: CD003200.
59. Searle A, Spink M, Ho A, et al. Exercise interventions
for the treatment of chronic low back pain: a systematic
review and meta-analysis of randomised controlled trials.
Clin Rehabil 2015; 29(12): 1155–1167.
60. Bleakley CM, Taylor JB, Dischiavi SL, et al. Rehabilitation
exercises reduce reinjury post ankle sprain, but the content
and parameters of an optimal exercise program have yet
to be established: a systematic review and meta-analysis.
Arch Phys Med Rehabil 2019; 100(7): 1367–1375.
61. Anderson L, Brown JPR, Clark AM, et al. Patient edu-
cation in the management of coronary heart disease.
Cochrane Database Syst Rev 2017; 6: CD008895.
62. Murphy LA, Harrington P, Taylor SJ, et al. Clinical-
effectiveness of self-management interventions in chronic
obstructive pulmonary disease: an overview of reviews.
Chron Respir Dis 2017; 14(3): 276–288.
63. Lenferink A, Brusse-Keizer M, van der Valk PD, et al.
Self-management interventions including action plans for
exacerbations versus usual care in patients with chronic
obstructive pulmonary disease. Cochrane Database Syst
Rev 2017; 8: CD011682.
64. Fryer CE, Luker JA, McDonnell MN, et al. Self manage-
ment programmes for quality of life in people with stroke.
Cochrane Database Syst Rev 2016; 8: CD010442.
65. Cheng KKF, Lim YTE, Koh ZM, et al. Home-based
multidimensional survivorship programmes for breast
cancer survivors. Cochrane Database Syst Rev 2017; 8:
CD011152.
66. Huang J, Han Y, Wei J, et al. The effectiveness of the
Internet-based self-management program for cancer-
related fatigue patients: a systematic review and meta-
analysis. Clin Rehabil. Epub ahead of print 3 December
2019. DOI: 10.1177/0269215519889394.
67. Mulligan H, Wilkinson A, Chen D, et al. Components
of community rehabilitation programme for adults with
chronic conditions: a systematic review. Int J Nurs Stud
2019; 97: 114–129.
Wade 13
68. Ramsay P, Salisbury LG, Merriweather JL, et al. A rehabili-
tation intervention to promote physical recovery following
intensive care: a detailed description of construct develop-
ment, rationale and content together with proposed taxonomy
to capture processes in a randomised controlled trial. Trials
2014; 15: 38, http://www.trialsjournal.com/content/15/1/38
69. Schmidt AM, Terkildsen Maindal H, Laurberg TB, et al.
The Sano study: justification and detailed description of
a multidisciplinary biopsychosocial rehabilitation pro-
gramme in patients with chronic low back pain. Clin
Rehabil 2018; 32(11): 1431–1439.
70. Westerhof-Evers HJ, Visser-Keizer AC, Fasotti L, et al.
Social cognition and emotion regulation: a multifaceted
treatment (T-ScEmo) for patients with traumatic brain
injury. Clin Rehabil 2019; 33(5): 820–833.
71. Wells M, Williams B, Treweek S, et al. Intervention
description is not enough: evidence from an in-depth mul-
tiple case study on the untold role and impact of context
in randomised controlled trials of seven complex inter-
ventions. Trials 2012; 13(1): 95, http://www.trialsjournal.
com/content/13/1/95
72. Peiris CL, Taylor NF and Shields N. Additional Saturday
Allied Health Services increase habitual physical activity
among patients receiving inpatient rehabilitation for lower
limb orthopedic conditions: a randomized controlled trial.
Arch Phys Med Rehabil 2012; 93(8): 1365–1370.
73. Peiris CL, Taylor NF and Shields N. Patients value patient-
therapist interactions more than the amount or content of
therapy during inpatient rehabilitation: a qualitative study.
J Physiother 2012; 58(4): 261–268.
74. Hsu C-D, Cohn I and Caban R. Reduction and sustain-
ability of cesarean section surgical site infection: an
evidence-based, innovative, and multidisciplinary quality
improvement intervention bundle program. Am J Infect
Control 2016; 44(11): 1315–1320.
75. Chaudhary N, Varma V, Kapoor S, et al. Implementation
of a surgical safety checklist and postoperative outcomes:
a prospective randomized controlled study. J Gastrointest
Surg 2015; 19(5): 935–942.
76. Waters RA and Buchanan A. An exploration of person-
centred concepts in human services: a thematic analysis of
the literature. Health Policy 2017; 121(10): 1031–1039.
77. The American Geriatrics Society Expert Panel on
Person-Centered Care. Person-centered care: a definition
and essential elements. J Am Geriatr Soc 2016; 64(1):
15–18.
78. Olsson L-E, Jakobsson Ung E, Swedberg K, et al. Efficacy
of person-centred care as an intervention in controlled
trials – a systematic review. J Clin Nurs 2013; 22(3-4):
456–465.
79. Ballard C, Corbett A, Orrell M, et al. Impact of person-
centred care training and person-centred activities on
quality of life, agitation, and antipsychotic use in peo-
ple with dementia living in nursing homes: a cluster-
randomised controlled trial. PLoS Med 2018; 15(2):
e1002500.
80. Spoorenberg SLW, Wynia K, Uittenbroek RJ, et al. Effects
of a population-based, person-centred and integrated care
service on health, wellbeing and self-management of com-
munity-living older adults: a randomised controlled trial
on Embrace. PLoS ONE 2018; 13(1): e0190751.
81. Guidetti S, Ranner M, Tham K, et al. A ‘client-centred
activities of daily living’ intervention for persons with
stroke: one-year follow-up of a randomized controlled trial.
J Rehabil Med 2015; 47(7): 605–611, http://www.medical-
journals.se/jrm/content/html/10.2340/16501977-1981
