A professional’s guide to functional rehabilitation
by Rachael Hargreaves
What is functional rehabilitation?
When occupational therapists refer to functional rehabilitation they are describing a process by which a client is supported to return, as far as possible, to their previous level of participation in daily activities. The client’s previous level of functioning (prior to injury/accident/illness) is ascertained through conversation and history taking and this, along with reference to their prognosis and current abilities, allows the therapist to support the client to set rehabilitation goals. The type and nature of the goals set by clients will vary depending on their values and interests. For example, some clients may value being able to wash and dress themselves independently, whilst others may place more importance on being able to access their local shops or visit friends and family.
Why are occupational therapists paramount in this process?
Occupational therapists (OTs) are trained and experienced in activity analyses, the principal element of functional assessment and rehabilitation. This skill is the central component of occupational therapy practice and allows therapists to understand activities and occupations in relation to the demand it places on a person. For example, the task of preparing a meal could initially be thought of as an activity based purely around physical ability. However, when the activity is examined in more detail much more information can be teased out and drawn upon. This information may include; whether the client has the executive skills to first of all plan how to cook their chosen meal, whether they are able to initiate the task without prompting and sequence the various stages, remembering each as they are completed. Further investigation would include whether the client can access the shops to purchase the necessary ingredients and whether they have the fine motor skills to open jars or chop vegetables and so forth.
Occupational therapists naturally take this holistic approach and use their skills to ask the right questions in order to ascertain a person’s level of cognition in relation to tasks. They will observe clients completing activities in order to gain a perspective of how they manage. It may seem like an incongruous or perhaps even an inappropriate request to ask a person to demonstrate how they get on and off of their toilet, however OT’s know that by observing this task they gain such valuable insight. As they say, a picture paints a thousand words and observation really helps to guide professional judgement. By observing and analysing activities of daily living occupational therapists not only get to examine how a client is able to manage a particular task but can also then gage how any observed difficulties may impact on other tasks such as in work or the community. In addition, they gain an understanding of the person’s safety awareness and thought processing surrounding the activity. For example, an amputee client reports that they are independent and managing toilet transfers, yet when assessed by the OT it is discovered that they are in fact putting themselves at risk by pivot transferring 180 degrees without any hand rails or equipment. The occupational therapist may advise the amputee how to manage the transfer in a safer manner during the assessment and then may recommend hand rails or a slide board to further assist.
What does a functional assessment involve?
A functional assessment, sometimes referred to as an ADL (activities of daily living) assessment, is completed as part of the initial OT assessment and is documented within the relevant sections of their report. The process involves:
- taking an accurate history from the client and medical records
- gathering information as to what activities are important to the client
- assessing and analysing the client completing activities of daily living, thus including; their orientation to the task, their planning skills, their sequencing of the task, their safety awareness and their motor control, coordination and balance
- advising the client on techniques to aid participation and alleviate risks, for example how to manage fatigue during activities or how to get up from the floor after a fall
- setting client centred SMART goals to guide rehabilitation and intervention
In many cases clients will be able to take on board advice given by the OT during the initial assessment and with equipment/techniques continue their rehabilitation at their own pace. Contrariwise, others may require more structured and intense rehabilitation programs with follow up sessions focusing on practising an activity using different treatment approaches.
What type of treatment approaches are used?
The two main treatment approaches used in functional rehabilitation are the compensatory and restorative approaches. These approaches belong to corresponding frames of reference which are used to guide occupational therapy practice. The restorative approach forms part of the biomechanical frame of reference which places emphasis on restoring previous function via participation in activity. The grading of activities is often used with in this approach and by gradually increasing the task demand, a client may gradually return to their prior level of functioning. For example, a client with reduced balance may first be able to sit and practise washing their upper body each morning before progressing to standing up to don their lower half garments. In concordance with this may be balance exercises at intervals throughout the day in order to further promote improvement. The compensatory approach forms the basis of the rehabilitative frame of reference in which the aim is to modify the demand a task places on the person. This may be achieved by teaching different techniques and strategies or may include the provision of assistive equipment and aids. Both approaches may be used in conjunction, for example, the client may require the use of a hand rail to stand when donning their lower half garments to compensate for loss of balance if it is not fully restored.
When to refer a client for functional rehabilitation
Anyone who has suffered injury, illness or loss of function, be it long or short term will likely benefit from some form of rehabilitation. As aforementioned, it is not always clear through conversation just how well a person is coping with a certain activity. Hence the value of an occupational therapist casting their professional eye in order to fully assess, make recommendations and highlight any risks. Any queries or enquiries can be discussed with one of The OT Practice client managers by calling 0330 024 9910 or by emailing [enquiries@theotpractice.co.uk](mailto: enquiries@theotpractice.co.uk).
