Week 1 - Concepts of Rehabilitation and Evidence-Based Practice.pdf

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 1 Concepts of Rehabilitation and Evidence- Based Practice Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Concepts of Rehabilitation and Evidence-Based Practice BASIC CONCEPTS Basic Concepts What, why, when, how, where and who These are questions that are continually asked in health care Knowing the answers to them is not always easy or even possible – Understanding them can be even more difficult Trying to know and understand the answers, however, is the goal of health care professionals Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 4 Basic Concepts It is one thing to merely do something, and another to understand why something is done The challenge does not lie in applying a weight to an ankle but in knowing why it is done, when it should be done and what impact this action has on the body Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 5 Professional Practice The Accredited Exercise Physiologist (AEP) must act professionally toward all rehabilitation team members Your consideration, respect for others, confidence, honesty and sincerity inspire the patient to comply with the rehabilitation program you provide and reassure parents, physicians and other team members that you have the knowledge, ability and skill required to manage their rehabilitation Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 6 Professional Practice The AEP needs good active listening skills. Being an active listener means being involved in the conversation, participating appropriately and understanding what the other person is saying Beyond listening, the clinician must also communicate his or her thoughts accurately. It is best to use common language that is easy to understand rather than medical jargon when speaking with patients and other lay persons Be sure to explain yourself clearly and precisely. Make your explanations simple and to the point so that your ideas will be less likely to be misunderstood Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 7 Professional Practice - Teamwork It is important for physicians and rehabilitation clinicians to know and understand each other’s rehabilitation philosophies and preferred methods of treatment before a rehab program begins It is not unusual for rehabilitation clinicians and physicians to differ in their perspectives, but it is important for them to reach common ground so they can respect their differences and work with each other to achieve what they both ultimately want: a patient’s successful rehabilitation outcome Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 8 Professional Practice – Compliance – The Home Program The rehabilitation process should almost always include a home program for the patient. This not only enhances rehabilitation but also allows the patient to bear responsibility for their own progress When providing home program instructions, you should give as few instructions at one time as possible, and those instructions should be reinforced with a handout or some method of recall Providing the patient with written as well as verbal instructions does even more in assuring compliance Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 9 Concepts of Rehabilitation and Evidence-Based Practice QUALITIES OF PROFESSIONALISM Being a Professional The needs of professionals are met through the profession’s society or association For you, this is ESSA (Exercise and Sports Science Australia) The society’s or association’s needs are met through the active participation of its members Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 11 Being a Professional Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 12 Ethical and Legal Standards Healthcare professionals (AEPs included) have a responsibility to themselves, to their profession, to their employers and to the patients they rehabilitate to act in a consistently professional manner, including following ethical and legal guidelines National Code of Conduct for Healthcare Workers (state-based implementation) https://pacfa.org.au/portal/Portal/Prac-Res/Resources/Gov-Code- Cond.aspx Queensland link (from ESSA website) https://www.health.qld.gov.au/__data/assets/pdf_file/0014/444101/nation al-code-conduct-health-workers.pdf ESSA Code of Professional Conduct and Ethical Practice file:///C:/Users/timiller/Downloads/ESSA%20Code%20of%20Professional% 20Conduct%20and%20Ethical%20Practice_181120%20(4).pdf Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 13 Rehabilitation “The process of treatment and education that help disabled individuals to attain maximal function, a sense of well-being, and a personally satisfying level of independence” (Taber’s Cyclopedic Medical Dictionary) “A set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments” (World Health Organisation) Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 14 Ethical and Legal Standards - Consent AEPs use their professional skills, knowledge and best professional judgement to decide the course of rehabilitation for a patient Sometimes a patient may not wish to follow the course of treatment the clinician has proposed – the patient may refuse to perform a specific activity Although you may try to convince the patient that the activity is appropriate for a variety of reasons, you must remember that if the patient refuses to perform the activity you request, you cannot force the patient to do it Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 15 Ethical and Legal Standards - Consent The patient always has the last say on what is or is not done with or to their body Patients give consent for treatment by performing what is requested during the rehabilitation program, but they always have the right to say “no” The patient’s consent is assumed to be given in the treatment process until it is taken away As an AEP, or any health professional, you must always respect the patient’s right to consent to or refuse treatment Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 16 Ethical and Legal Standards - Touch Touch becomes something that AEPs often do not think about, yet you must be continually sensitive to the patient’s perception of your touch Touching a patient should always be purposeful (not casual), with a specific reason and goal in mind Touching is an integral and necessary part of an AEP’s duties, but you must be acutely aware that a patient may not be accustomed to the intimacy of touch in this context Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 17 Ethical and Legal Standards - Touch Before you place your hands on a patient or perform a specific task, you must always explain to the patient what you intend to do and why Presenting yourself in a professional manner, being deliberate in how you touch, demonstrating respect for the patient and having sensitivity for the patient’s situation help to reassure the patient and permit you to perform your tasks appropriately Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 18 Ethical and Legal Standards - Touch If you are dealing with a patient whose cultural rituals and restrictions are not familiar to you, ask the patient’s permission before you place your hands on them In today’s litigious environment, touch – even when it is purely professional and necessary – can be questioned Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 19 Ethical and Legal Standards - Touch If you find yourself in an isolated situation or if you think that questions may arise later, you should take precautions: Have another professional or someone else present Keep the treatment door room open Provide the treatment in a common room where others are present It is often wise to listen to your instincts. If you have an uneasy feeling about a situation, be cautious Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 20 Ethical and Legal Standards – Personal Response and Needs Everyone responds differently to an injury and to the subsequent rehabilitation program. Expecting a patient to progress in the same manner as the last patient you had with the same, or a similar, injury can prove to be frustrating for both you as the clinician and the patient Individual physiological and biochemical differences can profoundly affect a patient’s responses to an injury Other non-physical variables can also influence a patient’s recovery: Outside support from friends, teammates and/or family The patient’s psychological makeup and response to the injury The degree and types of outside pressures the patient may feel The goals and rewards the patient may want to achieve The program should be guided and designed based on the responses of each patient Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 21 Concepts of Rehabilitation and Evidence-Based Practice COMPONENTS OF A REHABILITATION PROGRAM: PRINCIPLES, OBJECTIVES AND GOALS Principles There are seven principles of rehabilitation: Avoid aggravation Timing Compliance Individualisation Specific sequencing Intensity Total patient Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 23 Avoid Aggravation Therapeutic exercise, if administered incorrectly or without good judgement, can make the injury worse Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 24 Timing The therapeutic exercise portion of the rehabilitation program should begin as soon as possible without aggravating the injury. The longer the therapeutic exercise is delayed, the longer the recovery process will take After injury, rest is sometimes necessary. Studies have demonstrated, however, that too much rest is actually detrimental to recovery During the first week of immobilisation, 3 – 4% of an individual’s strength is lost each day. This strength cannot be recovered in an equivalent amount of time; recovery takes much longer Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 25 Compliance A patient must be compliant if the rehabilitation program is to be successful. The patient will be more compliant when they are better aware of the program to be followed and its rationale, the work they will have to do and the anticipated outcomes Knowledge empowers the patient Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 26 Individualisation Each person responds differently to an injury and to the subsequent rehabilitation program Expecting a patient to progress in a program the same way as the last patient you had with a similar injury will prove to be frustrating for both you and the patient Individual physiological and biochemical differences profoundly affect a patient’s responses to an injury. Several other non-physical variables can also influence the recovery of the patient Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 27 Specific Sequencing A specific sequence of events should be followed in a therapeutic exercise program This specific sequence coincides with the body’s physiological healing response Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 28 Intensity The intensity level of the therapeutic exercise program must challenge the patient and the injured area, but at the same time not be too severe as to aggravate the injury Knowing when to increase intensity without over-taxing the injury requires observation of the patient’s response and knowledge of the healing process For you to use the correct exercise intensity in a therapeutic exercise program, knowledge of the progression of exercises and the amount of stress that each exercise imposes is also important Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 29 Total Patient You must consider the total patient in the rehabilitation process It is important for the injured person to stay conditioned in the unaffected areas of his or her body This means keeping the cardiovascular system at a pre-injury level and maintaining range of motion, strength, coordination and muscle endurance of the uninjured segments Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 30 Objectives Objectives are desired outcomes There are three basic objectives for any therapeutic exercise program: 1) Prevent deconditioning of the uninjured areas 2) Rehabilitate the injured area in a safe, efficient and effective manner 3) Return to optimal function as a contributing team member Because of the nature of the injury or medical restrictions involved, it may sometimes take some imagination on your part to develop exercises that challenge the uninjured parts while not harming the injured area Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 31 Examination and Assessment To create short- and long-term goals, you must first establish the current status of the deficient parameters through examination and assessment You then decide what realistic short-term goals the patient can achieve in a specific amount of time Once those goals are achieved, you once again perform an examination and make an assessment to decide upon new and appropriate short-term goals Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 32 Examination Examination – The process by which the clinician gathers subjective and objective information to identify the patient’s injury and define deficiencies so that an appropriate rehabilitation program can be designed Rehabilitation programs are based on a problem-solving approach to the patient’s injury, deficiencies and goals Clinicians continually examine and re-examine their patients throughout the rehabilitation program. This re-examination enables you to determine whether your treatment is beneficial or not Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 33 Key Examination Concepts Reliability – Is how often a test will produce consistent results under the same conditions Intrarater Reliability – How consistent the test is when the same clinician uses the test more than once and on different patients and has the same results Interrater Reliability – How consistent the test is when a group of clinicians uses the same test on the same patients and has the same results Reliability measures are expressed as either kappa or ICC (intraclass correlation coefficient) When the reliability is close to 1.0 for either kappa or ICC, it means that the test is more reliable than a test that has a reliability score farther from 1.0 Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 34 Key Examination Concepts Validity – Is the degree to which a test measures what it is intended to measure Gold Standard – Is the criterion measure or test that is the best at producing the most accurate results, and it is the standard by which all other measures or tests that propose to produce the same outcome are assessed Sensitivity – Is a test’s ability to produce a positive result when the condition being tested for is really present. Also known as a true positive Specificity – Is a test’s ability to produce a negative result when the condition being tested for isn’t present. Also known as a true negative The closer the specificity and sensitivity ratings are to 1.0, or 100%, the more reliable they are for producing the correct results Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 35 Problems Following an examination and assessment of a patient’s injury or illness, the clinician creates a list of problems that should be addressed in the treatment program This list is recorded with the greatest problems or most significant deficiencies listed first, with the other problems following in descending order of importance This problem list serves as a guide to setting goals for resolving those issues. There should be a goal for every problem identified Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 36 Goals In therapeutic exercise the ultimate goal is the return of the patient to their optimal level of activity; most often but not always, this is a return to the patient’s former level of function There is often a fine line between going too slowly and progressing too quickly. The program should stress the patient just enough to provide gains, not losses, with regular progression Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 37 Objective and Measurable Goals Goals should be objective and measurable whenever possible Goals are occasionally subjective; for example, pain measures are subjective. However, some objectivity is possible in measuring pain by asking the patient to rate his or her pain on a 10-point scale Other parameters such as girth, range of motion and strength are measurable, objective goals Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 38 Short- and Long-Term Goals When an injury is severe enough to restrict sport participation or normal activity for at least one month, both long-term and short-term goals should be set A long-term goal is the final, desired outcome of a therapeutic exercise program Short-term goals provide both you and the patient with objective aims to guide you toward the long-term goals A short-term goal may be to reduce oedema by 1cm and increase range of motion by 15⁰ in one week. Other short-term goals may be to increase strength by half a grade, reduce pain to 3 on a scale of 0 to 10, and ambulate with one crutch in 5 days Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 39 Short- and Long-Term Goals Short-term goals should be reasonable and attainable, yet challenging for the patient It is easier to recognise progress when we focus on short-term goals Establishing realistic goals takes skill, knowledge, practice and judgement on your part as the practitioner Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 40 Progression A good therapeutic exercise program progresses in a challenging yet safe manner A good progression challenges the patient without causing deleterious effects such as increased pain or swelling or decreased ability to perform Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 41 Concepts of Rehabilitation and Evidence-Based Practice EVIDENCE-BASED PRACTICE AND OUTCOMES- BASED PRACTICE Evidence-Based Practice Evidence-Based Practice – What has been demonstrated to produce the best results in practice Evidence-based practice is the application of information gleaned from current, quality research that is combined with the clinician’s skills and experience, along with the patient’s needs, goals and priorities, to create and provide the patient with the best and most appropriate level of care It’s the clinician’s responsibility to critically review and assess the investigation for its quality In addition to empirical evidence, evidence-based practice relies on the clinician’s anecdotal evidence The clinician’s anecdotal evidence is obtained either from their own experience or the experience of others in using a clinical technique or application and then assessing those results. Clinicians who find success using a certain technique are likely to use it with subsequent patients and continue to assess the results until they are convinced of its effectiveness Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 43 Evidence-Based Practice In summary, AEPs decide what rehabilitation techniques and applications to use based on three factors (these elements do not necessarily have equal weighting): Empirical evidence Their own clinical experience or that of others The goals, needs and desires of the patient Designing a rehabilitation program based on all three elements of evidence-based practice is sound clinical practice Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 44 Outcomes-Based Practice The assessment of outcomes in clinical practice is important in healthcare record keeping. Not only can it help the clinician in providing useful information about patient perceptions of treatment quality and effectiveness, but it can be especially valuable when clinicians bill for their services; third-party providers often require evidence of outcomes to approve further treatment (particularly in CTP, WC and NDIS claims) Outcomes can be based on various criteria, including clinician or patient perspectives Clinician-Based Outcomes – Deal more with objective criteria such as changes in range of motion, strength and coordination Patient-Based Outcomes – Based on the patients’ perceptions of how well they perform within their own life requirements Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 45 Outcomes-Based Practice Other outcomes are based on the various interests of other stakeholders, such as employers who are concerned with the employee returning to work, or insurance companies whose primary interest is in cost-effective outcomes Outcomes Tool – Most often a questionnaire that is given before the start of the treatment or rehabilitation program, sometime during its course, and at its conclusion Outcomes Tools are divided into two categories: General health status measurement tool Region-specific measurement tool Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 46 Outcomes-Based Practice A general status measurement tool is used to assess a patient’s overall physical, social and emotional health and is used for a variety of illnesses and treatment environments. These are often referred to as Quality of Life questionnaires/tools The gold standard for the general health status tool is the SF-36 https://www.rand.org/health-care/surveys_tools/mos/36-item-short- form/survey-instrument.html A variety of condition-specific outcomes tools have been created over the past several years to more accurately examine and assess items that are related to specific injuries or illnesses and reveal improvements in patient conditions with treatment applications. Tools specific for patient outcomes related to low-back pain, hip, knee, ankle and upper extremity have been developed and published Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 47 Concepts of Rehabilitation and Evidence-Based Practice BASIC COMPONENTS OF THERAPEUTIC EXERCISE Basic Components of Therapeutic Exercise If the therapeutic exercise program is to be effective, specific parameters must be addressed sequentially. Each of these parameters must be restored to at least pre-injury levels if the patient is to safely resume full sports participation or normal activity. These parameters in their proper sequence are: 1) Examination / assessment and problems and goals lists 2) Correct deviations and decrease pain 3) Flexibility and range of motion 4) Strength and muscle endurance 5) Neuromotor control and proprioception 6) Functional activity 7) Performance-specific activity Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 49 Basic Components of Therapeutic Exercise Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 50 Basic Components of Therapeutic Exercise A rehabilitation program is more understandable when it is divided into units or phases, as shown in the pyramid on the previous slide However, the body never works in such clearly delineated phases. There is always overlap between phases. For example, during the phase when flexibility is emphasised, some strengthening may also occur Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 51 Basic Components of Therapeutic Exercise It should be noted that the pyramid’s second level includes correction of deviations, which includes relief of pain and other secondary effects of injury such as joint effusion or oedema and muscle pain Correcting deviations is an important aspect of rehabilitation programs that deal with non-acute injuries. This element applies to injuries that develop over time (such as tendinopathies) and are not the result of a sudden trauma This added second-level pyramid step includes identifying the precipitating factors – aetiological factors – that cause the injury to occur. This is a crucial step in rehabilitating chronic or repetitive injuries because if steps are not made to identify the reason the patient developed the condition, the problem will return once the patient resumes normal activities. In these cases, AEPs take on the role of detective to identify the source of pathology and make efforts to correct deviations and causative factors Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 52 Flexibility and Range of Motion Achieving flexibility early in the therapeutic exercise program is necessary for two important reasons: 1) The activities that follow require good mobility of the affected area 2) It has an impact on the healing process Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 53 Flexibility and Range of Motion As injured tissue heals, scar tissue forms. As scar tissue matures, it contracts and becomes more permanent. These effects are important in eventually minimising the scar, but they can also be detrimental because as the tissue forms, contracts and matures, it attaches to, and pulls on, adjacent tissue and becomes stronger with improved adhesive bonds, causing loss of motion of soft tissue structures in the area and of joints when scar tissue crosses a joint Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 54 Flexibility and Range of Motion During healing there is a window of opportunity during which scar tissue mobility can be influenced and changed. Once that time frame has passed, the likelihood of successfully achieving full range of motion is diminished considerably In other words, if tissue mobility and flexibility are not addressed while the scar tissue is young and immature, soft-tissue adhesions in the area will restrict joint motion and mobility in an extremity Although restoration of other parameters is also sought during the first stage of treatment, flexibility must be the primary emphasis Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 55 Strength and Muscular Endurance As an injured site’s healing and mobility progresses and healing tissue matures to tolerate additional stresses, achieving normal strength and muscular endurance becomes the priority With any injury, some strength is lost. The amount of strength and muscle endurance lost depends on the area injured, the extent of the injury and the amount of time the patient has been disabled by the injury Remember that muscle strength and endurance are two dimensions within a continuum of muscle resistance Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 56 Neuromotor Control (Balance, Agility and Coordination) It is too often assumed that because range of motion and strength are restored, the patient is ready to resume full sport participation or normal activity. This is not the case at all Impairment of the neuromotor system often accompanies orthopaedic injuries, either because the neuromotor elements themselves are injured or because lack of use or restricted use causes performance to decline. In either case, neuromotor training must be incorporated into the rehabilitation program to restore what has been lost Both the central nervous system and the peripheral nervous system need re-education to restore neuromotor performance Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 57 Functional and Performance-Specific Activity Function and performance are the final two phases of rehabilitation before the patient is released from the rehabilitation program. Functional activities should precede performance activities Accurate execution of functional and performance-specific skills requires the attainment of all previous parameters first Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 58 Concepts of Rehabilitation and Evidence-Based Practice PREHABILITATION Prehabilitation Prehabilitation is the use of therapeutic exercises in advance of a surgical procedure to improve the functional capacity of the patient so that the patient may withstand the effects of inactivity after an orthopaedic surgery It has been demonstrated that patients who perform pre-operative exercises do better post-operatively in both short-term and long-term results Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 60 Prehabilitation Whatever strength level the patient has at the time of surgery is reduced after surgery; it makes intuitive sense, then, that the more strength a patient has prior to surgery, the more strength they will have immediately after surgery Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 61 Prehabilitation Studies have demonstrated that patients undergoing prehabilitation not only recover from surgery better, but their strength gains are more rapid after surgery, and they have less post-operative pain Efforts to optimise range of motion and soft tissue mobility along with gains in strength and function are also part of the prehabilitation program Treatments should stay within the patient’s pain tolerance and should not aggravate the existing condition Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 62 Concepts of Rehabilitation and Evidence-Based Practice RETURN-TO-COMPETITION CRITERIA Return-to-Competition Full readiness to resume sport participation means that the injured area has no pain, swelling or atrophy and has full range of motion, flexibility, strength and endurance It also means that the patient can perform the sport skills and coordination tasks at an appropriate functional level Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 64 Return-to-Competition You and the patient must remember that the Physician (often an Orthopaedic Surgeon, but occasionally a Sports and Exercise Physician) has the final word on when the patient can return to competition It is through your communication with the Physician about the patient’s response to treatment, the patient’s ability to perform activities required in the sport and the injured area’s status that the Physician can make that determination Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 65 Concepts of Rehabilitation and Evidence-Based Practice PSYCHOLOGICAL CONSIDERATIONS Stages of Grief Many psychological factors have a direct and sometimes profound influence on the overall results of the rehabilitation program Grief is an emotion that occurs after an episode where a person experiences loss. One of the more accepted and adapted explanations of grief was provided by Kubler-Ross Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 67 1) Denial At first, the patient doesn’t believe that the injury is severe and feels that they will return to competition in a day or two Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 68 2) Anger As reality of the severity and consequences of the injury set in and the patient is forced to see the difficulty they are having in recovery, the patient expresses anger as a release of genuine feelings of frustration and helplessness. This anger is often directed at whomever is present Attempts to calm, rationalise with, or help the patient to see what is really happening are often futile at this point The patient wants only to express this anger and does not want to be told why they should not be angry or that things will get better During this stage, you should try to prevent the injury from becoming aggravated by any harmful activities the patient may attempt Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 69 3) Bargaining Injured patients may bargain with the Physician, other health care providers (including you), or even God The patient is inclined to bargain with individuals involved in patient care: “If you let me do this (usually something the patient wants to do rather than what they should do), I promise to do that (whatever it is the clinician has instructed the patient to perform)” Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 70 4) Depression As the patient begins to understand the reality of the situation, depression is the next stage The patient’s self-worth declines during this time. The patient feels that they have no physical or emotional control It is during this phase that rehabilitation becomes the most difficult for both the clinician and the patient. It becomes difficult for the patient to comply with the rehabilitation program. The patient may not attend scheduled treatment sessions or may not fully participate in them Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 71 5) Acceptance In this final phase the patient begins the battle of fighting the physical limitations and psychological downswing experienced during the previous stages Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 72 Progression Through the Stages Throughout the grieving process there are no abrupt changes; rather, the patient goes through gradual transitions, and fluctuation between stages can occur. You must be aware that these swings occur and are natural Do not take any verbal attacks or outbursts the patient may make during this emotional and psychological recovery personally; remember that the patient is following a normal grieving process When a patient cannot advance through the grieving process smoothly, or if you are concerned about the patient’s emotional condition, it is your responsibility to support the patient and encourage them to seek additional psychological support from their General Practitioner, a Counsellor, Psychologist or Psychiatrist You should never hesitate to refer a patient to an appropriate specialist Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 73 The AEP’s Role in Psychological Recovery It has been shown that individuals best retain instructions when they receive no more than two exercises at a time for their home program A patient who is feeling stress because of the injury, has concerns about his or her future, or is in pain will have a reduced ability to recall your instructions Having the patient perform the home program before they leave your clinic and providing written descriptions of exercises along with illustrations or photos ensures better patient recall and compliance with a home program Week 1 - Concepts of Rehabilitation and Evidence-Based Practice 74