Rehabilitation

Rehabilitation is the restoration, maintenance, or improvement of former capacity, function, or condition. Medical rehabilitation (colloquially referred to as “rehab”) deals with the rehabilitation of physical and/or psychological function impaired by a medical condition. Medical rehabilitation typically addresses the consequences of acute (e.g., fracture, stroke) as well as chronic conditions (e.g., COPD, chronic pain) following or complementing primary care, with orthopedic conditions being the most common indication. Measures of medical rehabilitation include follow-up treatments, physical therapy, psychotherapy, counseling, and education. Medical rehabilitation can be distinguished from social rehabilitation, which is the restoration, maintenance, or improvement of social standing, privileges, and/or participation in response to circumstances with negative social and/or economic effects on the individual. Combinations of medical and social rehabilitation strategies may be indicated when the medical condition affects not only the health but also the social and economic situation of an individual (e.g., if addiction or disability leads to downward social movement).

Medical rehabilitation

Medical rehabilitation is the restoration, maintenance, or improvement of physical and/or psychological function after the treatment and/or resolution of a medical condition. Accordingly, while primary treatment is aimed at the manifestations of a medical condition, rehabilitation is aimed at its consequences. The following points must be considered before initiating rehabilitation:

• Necessity
  • Assess the likelihood that and the degree to which patient function will remain impaired if the patient does not undergo rehabilitation.
  • Ensure that all options of primary treatment have been exhausted.
  • Rehabilitation is generally not indicated for:
    • Conditions that will likely resolve spontaneously
    • Conditions that require only limited outpatient care to restore, maintain, or improve patient function
• Ability: Assess whether the patient is psychologically and physically willing and able to undergo rehabilitation.
• Prognosis: Assess the probability that rehabilitation will effectively restore, maintain, or improve patient function.
• Goals
  • Determine whether the goal of rehabilitation should be restoration, maintenance, or improvement of function based on:
    • Patient willingness, wishes, and ability
    • The type and severity of the condition
  • Consider whether rehabilitation can halt or slow disease progression and, if not, to what extent this affects the prognosis of rehabilitation.
• Cost-benefit ratio: Weigh all benefits, including health, social, and economic, against the cost of rehabilitation (e.g., the cost of rehabilitation against the cost of early retirement)

Types of medical rehabilitation and services

• Medical rehabilitation is classified by patient group and/or indication.
• There is often overlap regarding the individual strategies (e.g., geriatric rehabilitation may involve psychiatric and physical rehabilitation as well).
• The services involved depend on the preceding condition, its severity, and inpatient vs. outpatient treatment setting.
• Medical rehabilitation may involve social rehabilitation (see below) if the condition or its consequences also affect the patient socially and/or economically (e.g., loss of employment due to illness/disability).

Social rehabilitation

• Any form of nonmedical rehabilitation aiming to restore, maintain, or improve social function and participation in response to circumstances with negative social and/or economic effects on the individual, e.g.:
  • Incarceration
  • Homelessness
  • Psychiatric disorders
  • Unemployment
  • Illness or disability
• Specific types and services of social rehabilitation include:
  • Criminal rehabilitation: the reintegration of individuals in society after serving a prison sentence
  • Vocational rehabilitation: the (re)integration of individuals with disabilities in the job market by helping them access, maintain, or return to employment
  • Assisted living
  • Self-help groups
• Social rehabilitation may follow or complement medical rehabilitation, e.g., criminal rehabilitation may involve drug rehabilitation, psychiatric rehabilitation, and vocational rehabilitation.

Weightbearing ^[1]

• Definition: the amount of weight that can be placed on an injured extremity after fixation
• Weightbearing grades
  • Nonweightbearing: extremity cannot bear any weight and requires full support (e.g., using crutches with a broken leg)
  • Touchdown weightbearing: extremity can bear little weight and requires substantial support (e.g., the foot may touch the ground for balance, but no significant weight can be applied)
  • Partial weightbearing: extremity can bear some weight, permitting a gradual increase in weightbearing exercises (e.g., standing upright and shifting the weight toward the injured leg while holding onto a stable object)
  • Weightbearing as tolerated: extremity can bear 50–99% of body weight
  • Full weightbearing: extremity can bear 100% of body weight

The rehabilitation setting depends on a variety of factors, including the severity of the condition, required care/services, patient support, home layout/equipment, and the disability and functional independence of the patient. Patients often transition through different settings throughout their recovery, and home health care may be required during outpatient services.

• Inpatient care
  • Inpatient rehabilitation facility (IRF)/rehabilitation hospital is reserved for more serious conditions (e.g., stroke, head injury, spinal cord injury) that require:
    • Intensive services
    • Coordinated care among multiple disciplines, doctors, and therapists
    • Continuous medical supervision
  • A skilled nursing facility (SNF) may be required after an injury or procedure (e.g., hip or knee replacement)
• Outpatient care
• Home health care

In the US, health insurance is required to cover medical rehabilitation.

• Taxpayer-funded insurance
  • Medicare/medicaid covers the following:
    • Skilled nursing facility
      • First 20 days at 100%
      • The remaining days with daily copayment
    • Inpatient rehabilitation facility
      • Up to the first 60 days at 100%
      • Together with a patient per-day charge determined by medicare for days 61–90, and possibly up to day 150 if using up to 60 lifetime reserve days of the per-day charge.
  • Federal/state employee health plans and veterans health administration also include rehabilitation coverage.
• Private health insurance: Policies vary greatly but generally cover some degree of rehabilitation.

There are many proposed methods for evaluating patient fitness and performance status when determining a management plan for rehabilitation. Some more common examples include:

• ”Get up and Go” test: a quick screening method for gait or balance issues to detect individuals who are very prone to falling
• National Institutes of Health Stroke Scale (NIHSS)
• Modified Rankin Scale: measures degree of disability/dependence after a stroke
• Katz Index of Independence in Activities of Daily Living
• The Lawton Instrumental Activities of Daily Living Scale
• Barthel Index: measures performance in activities of daily living
• Karnofsky Performance Status Scale
• ECOG Scale of Performance Status