Should rehabilitation goals reflect all aspects of functioning in relation to a biopsychosocial ICF perspective?, 2019, Riis-Djernaes et al

[Andy]

Purpose: To classify short-term and long-term rehabilitation goals and analyse how they capture functioning in a biopsychosocial International Classification of Functioning, Disability and Health (ICF) perspective.

Materials and methods: A retrospective study was conducted at two specialised outpatient multidisciplinary rehabilitation centres for polio survivors and accident victims. Rehabilitation goals extracted from patient journals were linked to the ICF according to linking rules.

Results: One hundred patients were included. Four hundred and eighty-seven short-term and long-term rehabilitation goals were linked to the ICF. Fifty-seven per cent were linked to Activity and Participation, 22% to Body Functions, 1% to Body Structure, 4% to Environmental Factors, 4% to Personal Factors, whereas 11% were not defined and 1% was not covered. The identified categories covered all ICF domains. The most frequent categories for short-term goals were d450 “Walking” and d570 “Looking after one’s health.” For long-term goals, d850 “Remunerative Employment” and d920 “Recreation and Leisure” were the most frequent.

Conclusion: The study showed challenges in capturing all aspects of biopsychosocial functioning in rehabilitation goals, particularly Contextual Factors. This study indicates that rehabilitation goals capture capacity rather than performance. Further research could highlight if functioning is captured in the rehabilitation plan, and in this way include both capacity and performance.

• Implications for rehabilitation
• Health professionals in a post-acute or long-term rehabilitation setting should pay attention to capacity and performance when rehabilitation goals are set.
  
  
• The rehabilitation plan should contain goals and a description of patient’s contextual factors and both should be equally valued and combined in a description of functioning.
  
  
• In a post-acute or long-term rehabilitation setting short-term and long-term goals are affected by the context. A longer rehabilitation intervention lead to goals linked to activity and participation.

Paywall, https://www.tandfonline.com/doi/full/10.1080/09638288.2019.1672108
Sci hub, https://sci-hub.se/10.1080/09638288.2019.1672108

 

[Unable]

Why are such studies (with loads of self-important words) given funding?

I mean I know people want to improve what they can do, but this whole “goal setting” notion can get taken too far.

It seems to me that a patient asked to set a goal is put in a Catch 22 situation.

Set a goal that you would really like (Climb mountains again) and you are being unrealistic, but set a careful goal that you think you might have a chance of attaining and you are not aiming high enough!

So how does a patient answer that question about goals? It’s a nonsense, and totally arbitrary.

And then consider the review appointment discussions. Whatever has happened, the patient will either fail (and have not tried hard enough, or be told they had set an unrealistic goal), or succeed (and be told their first goal was a bit too easy, so they’d better set another harder one!)

I don’t know - maybe I’ve just always been some-one that takes what I do to my full capacity, but why oh why do these professionals think they are somehow able to make people set better goals than their patients would have set alone, without therapist input?

I could understand it perhaps, if it was “priority setting”. Because that might involve an understanding that to achieve one goal another has to be dropped. (Eg. If I achieve my “cook dinner each night” goal, then I have to drop the “have coffee with a friend once a week” goal.)

Okay.... sorry .... maybe I have misinterpreted the aims of the study. Maybe I’m just more suspicious because of the push put on ME patients to “increase” what they do. Maybe the word “rehabilitation” just sets me off....

 

[Unable]

Okay here’s something that struck me:
Read the first arrow below, and tell me as a patient which would be the “Main Concept” for you?



I would say the main concept was “to have more energy”, and that would mean being able “to participate in leisure activities and journeys”.

Without the “more energy” the “activities and journeys” would be either impossible or decidedly unpleasant.

Am I missing something or does this really miss the point here?

 

[Andy]

Am I missing something or does this really miss the point here?

In my opinion it strongly suggests that the researchers believe that more energy will follow on from achieving those things i.e. their model of reduced energy is the typical depression one, where there isn't an issue with energy production , just motivation.

 

[Trish]

I've only read the abstract. It seems all they did was trawl through patient records to see how the therapists were recording goal setting - ie what sort of terminology was used.

Further research could highlight if functioning is captured in the rehabilitation plan, and in this way include both capacity and performance.

So it looks like this research was a pretty sterile exercise to check the recording by therapists was ticking the right boxes -

capacity - I want to have more energy, I want to have better body function, eg ability to walk further...

performance - I want to be able to prepare my meals, knit socks, climb mountains, go back to work...

It's nothing to do with helping patients more effectively, it's to do with ticking the right boxes.

 

[Wonko]

It does seem to be quite ambitious to be expected to find a job working as a mountain climbing chef whilst knitting socks - not to mention quite dangerous unless you have more than the expected number of hands.

Possibly more realistic goals would be better, maybe some involving toast, or cake, or even biscuits.

 

[rvallee]

I have no idea what is the point or aim here. The "BPS perspective" is strictly from the point of view of BPS practitioners and so not particularly relevant to understanding what patients need, which is self-evident but contradicts the BPS perspective so it ends up like intertwined gears that lock one another in place.

It is like asking chefs what their clients want to eat. They can't help with that, it's not them eating the food. At least chefs have a market-based feedback system: no customers = no money = failure. In medicine this feedback loop does not exist because there is no competition other than alternative medicine. It seems like the BPS "solution" is to create an alternative medicine with all the flaws of both and none of the benefits of either. The main reason people use alternative medicine is that its practitioners listen, something BPS doesn't do because it treats us like stupid children with a broken thought process.

This is just busywork, like Trish said it's an exercise in ticking boxes for the purpose of ticking boxes and with the endpoint of measuring whether the expected boxes have been ticked and the only valid answer is to tick all the boxes that were expected to be ticked.

I like that the implications are that the questions they asked should be paid more attention for the sole purpose that they asked them. This is beyond circular reasoning, it's circular execution of circular reasoning. Turns out it's not just programmers who should be concerned with infinite loops that lack a stop function.

 

[Snow Leopard]

The classification itself is here:
https://apps.who.int/iris/bitstream...d=E4FA0628374DF933232845E31A2204EB?sequence=1
It assumes a specific Model of Functioning and Disability (page 17)

The key point is identifying the true limiting factor, whether it is a bodily system, problems with goal setting or inclusion, or environmental factors.

The danger is when rehabilitation practitioners assume the limiting factor is due to goal setting, personal factors or environmental factors when it is in fact due to problems with body functions or body structures.

What I dislike about the methodology of the above study is the experts simply assume their allocation is correct, rather than (a) asking patients whether it is reasonable and (b) testing such in a clinical study, and importantly with objective and long term outcome measures, rather than the easily biased short term questionnaires.