Occupational Therapy Essay: Strategies And Barriers In Rehabilitation Programs.

Identity of the Client

Describe about the Occupational Therapy for Rehabilitation Programs.

Rehabilitation programs are crucial for resuming the active   lifestyle and recover soon from the injury or illness, that involves disability. The rehabilitation and recovery programs generally targets enhancement of patient’s willingness for recovery and support for easy and faster recovery process from the chronic illness. However, setting up goals is one of the preliminary steps, which determines the efficiency and time for recovery process. There are several injuries or illness, which needs assistance and support for faster recovery; for instance total knee replacement, total hip replacement, bone fracture and other major injuries (Abraham & Michie, 2008). Several barriers can hinder the proper procedure of rehabilitation technique, whereas there are some factors or strategies that can influence the rehabilitation and recovery procedure. To set the goals and priorities for rehabilitation and recovery process, health models or theories are used by the health care professionals, for ensuring the patient’s needs has been prioritized during the health care planning. In this context, the health care professional should assess the patient’s needs thoroughly before planning the rehabilitation sessions.

Support is one of the crucial aspects in the recovery and rehabilitation processes. It is because, empowerment of a disabled patient helps in stimulating them for faster recovery. Here in this assignment, the focus is the patient, Mr. X, who has knee replacement and facing difficulties in coping with his status and disabilities. Thus, based on his status and needs, his rehabilitation sessions would be planned. Here, in this assignment, the factors that were hindering the patient’s engagement in the recovery and rehabilitation will be discussed with the help of recovery related theories (Bertisch et al., 2014). On the other hand, the strategies that would help the patient’s engagement and their recovery would be included in this assignment. Finally, the barriers, facilitators and the recommended strategies would be summarized to provide a brief overview.

During my job period at a rehabilitation centre, I met one client Mr. X, who was facing difficulties in engaging with rehabilitation and recovery from severe illness. The client Mr. X is a 55 years old male, who have severe arthritis and suffering from severe pain at his left knee and mobility impairment. The medical professional recommended total knee replacement or arthroplasty of his left knee. After a successful surgery, the recovery period was quite difficult for Mr. X, as it was very difficult for him to stay at bed as a disable person. He was a cheerful and active person before is surgery. Now, his condition was not feasible to support his previous active role. Thus, he is becoming anxious and depressed due to his disability. The impaired mobility of Mr. X was making him demotivated hindering his social involvement. The patient needs appropriate rehabilitation and recovery strategies for his faster and easy recovery. Mr. X was having negative pain perception and poor perceived self-efficacy as well as pessimistic personality traits, which were significantly hindering his efficient engagement with the rehabilitation and recovery process (Bright et al., 2014). He was a negative perception that movements can cause additional pain except the surgical pain, which along with the persistent postoperative pain symptoms were the cause behind his poor quality of rehabilitation. All of these consequences were leading to his decreased activity after rehabilitation and reduced social involvement along with increased psychological issues.

Psychological Consequences of the Illness

Orthopedic surgery usually needs many months of rehabilitation for getting a successful outcome; however, there are several psychological factors that can influence pain perceptions of the patient, compliance with the rehabilitation and the outcomes from the patient treatment after orthopedic surgeries like a total knee replacement surgery. Total knee replacement is a complicated illness, which involve the replacement of knee with an artificial knee joining. The complicated surgery needs a long-term recovery and during this period, severe pain and disability usually stimulates the onset of negative psychological issues in the patients. Patients need proper care and support for better adherence with the recovery and rehabilitation processes after a total knee replacement surgery (Bright et al., 2011). It has been revealed from several literatures that the mobility impairment and loss of autonomy or independence causes isolation and behavioral changes in the patient. It has been seen that most of the patients shows non-adherence with the rehabilitation processes, due to depression and anxiety related symptoms. It has been argued that there is a strong relationship between psychological symptoms and pain and disability, this prevalence of psychological symptoms are high in the pre and postoperative stages in the patients, who have undergone knee and hip replacement.

 It has been revealed from the previous literatures that the depressive symptoms in knee and hip replacement are higher, i.e. 33.6 % in one study, compared to coronary heart diseases, cancer or diabetes (Bright et al., 2011). However, age is a key determinant of the psychological consequences of the knee replacement surgery. However, reviewing previous literatures, it has also been found that throughout the recovery period, the psychological symptoms are reduced gradually, with the decrease in pain and disability. It has been revealed that 12 months postoperative no further reduction in the depressive symptoms were found compared to 3 months postoperative. Studies have shown that treating patients with psychotherapy before the surgery can lead to better results after the total knee replacement surgery. However, studies have also shown that proper management and emotional support had led to better results with the patients having depressive or anxious behavior. However, it has been seen in many previous cases that the support of physiotherapist and other medical professionals reduced the time for recovery along with the symptoms of psychological consequences.

Lack of support is one of the major barriers in engaging clients in rehabilitation. In case o Mr. X, it has been noticed that he was not adhered to the treatment procedure, which was one of the key reason behind his extended recovery time. On the other hand, the willingness of the patient is another key barrier for the patient’s recovery, because, until the patient is not adhering with the rehabilitation process, the success of the process would be doubtful. Moreover, the education and awareness of the patient is very important in this context (Ellis-Hill, Paynem & Ward, 2008). Until the patient becomes aware of his status and the importance of his compliance with the rehabilitation process, the patient’s adherence with the treatment procedure would not be assured. In case of Mr. X, it has been noticed that he was aware of his current condition, but he was not aware of the pros and cons of the rehabilitation process and the importance of his compliance with the rehabilitation process. Once he will be aware about the facts, his adherence with the rehabilitation and recovery process will be enhanced. The unclear perception of the patient about the pros and cons of the recovery process is a key barrier. Negative perception, psychological issues and stress are the factors that can delay the recovery process by stimulating the negative perception about the disorder. In the case of Mr. X, he was not willing to take his medicines an d physiotherapies, due to severe pain and showed depression and anxiety. The behavioral changes affected his communication with the medical professionals and physiotherapist, which further worsened his recovery process. Lack of support from the medical professionals and the family, relatives and dear ones are also the major factor that acts as a barrier of engagement of the patient with the rehabilitation process.

Barriers in Engaging the Client in Rehabilitation

In this context, it has been revealed that the support from the patient’s family is lost, due to the independence of the patient. In the case of Mr. X, he was lacking the support from family and friends, which is the major reason behind his depression. One current study by Gollwitzer (1999) highlighted that the patients who got support from their family and friends, recover easily and faster, compared to the patients who do not get family support. Moreover, the lack of family and peer support is a major cause behind the negative emotions, which leads to the psychological problems, further reducing the patient’s recovery rate. Low progress takes more time to recover and longer recovery time reduces patient’s compliance and adherence with the treatment and rehabilitation process. As it takes more time to recover from the disabled state, loss of independence for longer period makes the patient anxious, agitated and irritated. This Happened to Mr. X, as he was facing difficulties in engaging with the rehabilitation and recovery process after his total knee replacement surgery.

Lack of competency in the medical professionals attending the patient in recovery or rehabilitation is another factor that can be a barrier of faster and easy recovery of a patient undergoing total hip and knee replacement. In case of Mr. X, lack of the development of professional relationship with the health care professional was the key cause of his reduced compliance with the rehabilitation process and delay in progress of the recovery process (Hall et al., 2010). Mr. was unable to maintain a good communication with the medical professionals, due to the lack of positive communication skills of the nurse or other medical professionals attending him. In this context, he was attending the rehabilitation process with low adherence and reported lack of motivation and support from the care providers including physiotherapist and other health care practitioners. Lack of patient’s assessment before setting the goals can lead to negative consequences or can lead to the unavailability of the patient’s support from the other health care professionals. These factors are responsible for patient’s non-adherence with the rehabilitation process and delayed recovery process. Moreover, lack of assessment of patient’s priorities also hinders the patient’s efficient recovery, because, the patient’s actual needs are not addressed during the rehabilitation procedure, leading to unrealistic goal settings, which does not provide expected outcomes. Thus, goal setting is a very important factor that can influence the patient engagement and lack of which can hinder the rehabilitation and recovery process.

Pain perception is another factor that can hinder a patient’s recovery and rehabilitation compliance. It is because, orthopedic patient usually have a perception that movement of the limb or the surgical area will put additional strain on their body, causing massive pain additional to the surgical pain. Unchanged perception leads to their decreased mobility, which is beyond the expectation in a rehabilitation process. This leads to stiffness of joints or other surgical area and persistence of the pain in the joints or other surgical areas, which hinders patient’s compliance with the rehabilitation and follow-up sessions. However, while concerned about the return of the patient to work after the orthopedic surgery and rehabilitation process, not only the physical and emotional status of the patient and support from his family and medical professionals are important, rather, support from the organization, other employees and other support groups are also have significant role. Harding andWilliams (1995) identified lack of information access, lack of support group, lack of understanding and collaboration from the employer were the most important barrier for a patient to return to his work. Thus, it can be said that persona, clinical, occupational and health service factors are also important for the patient to return to his work.

After orthopedic surgery including total joint replacement, i.e. total knee replacement or total hip replacement surgery, the total recovery and getting back to normal life before surgery, is a time consuming process. The recovery can be influenced and progress can be faster by the help of some facilitators of rehabilitation. One factor identified that has an important role in facilitating patient’s engagement in the rehabilitation process is knowledge about one’s limit and motivating the patient for physical training and movement of the surgical body parts.

Patient-centered approach- A patient centered approach in the rehabilitation sessions can influence the patient’s engagement in the recovery and rehabilitation process. It is because, the patient-centered approach tend to prioritize the patient’s needs from every aspects, including the physical, psychological, social and emotional. Patient’s well being is dependent upon all of these aspects and it contributes to patient’s overall recovery and gaining the normal life back (Harding & Williams, 1995).

Emotional support with respect and dignity- The most important factor-facilitating patient’s recovery and well-being is emotional support. In case of Mr. X, he was lacking an emotional support. Showing respect and dignity towards the patient, without any kind of biasness is the key of engaging and empowering the patient in his work. While handling patients like Mr. X, the practitioner should show respect towards the patient and prioritize patient’s feelings and perceptions. It enhances patient’s positive perception about the therapeutic procedure and engage patient with the rehabilitation procedure (Harris, 2006).

Goal setting based on patient’s needs- Goal setting is the basic step in the rehabilitation and recovery process after an orthopedic surgery. Goal setting determines the probability of getting expected outcomes through the rehabilitation process. In this context, assessment of the patient’s needs is very important. Assessing the physical and psychological status of the patient helps the health professional to understand the actual needs of the patient, based on which the therapeutic goals of rehabilitation are established. It enhances the possibility of getting success easier and faster. In contrast, setting unrealistic goals, without assessing the patient’s needs reduces the chance of getting success from the rehabilitation process (Kayes & McPherson, 2012).

Therapeutic alliance- Therapeutic alliance is referred to the relationship between the patient and health care professional. It is a very important facilitator of engaging patient in rehabilitation process after orthopedic surgery, through which Mr. X has undergone. Several literatures identified therapeutic alliance as an important determinant of patient engagement and positive health outcomes following rehabilitation. For this, the health care practitioners should have required skills and competence including good communication and coordination with the patient. Providing value to the patient’s view during the therapeutic work can help to enhance patient’s trust towards the therapist, which in turn can establish a positive relationship within the patient and the health care practitioner (Kayes et al., 2015).

Family support and engaging patient’s family in rehabilitation- Mr. X did not received enough family support, which is one of the significant determinants of the positive health outcomes following rehabilitation. Thus, in person-centered care, engaging patient’s family in the procedure is helpful. Involving patient’s family provides a homely environment to the patient, which eliminates the discrimination of the patient as a disabled person, thereby encouraging his engagement through the procedure.

Psychotherapy and counseling- Literatures has suggested that there is a significant connection between poor recovery and related outcomes with stress and depression related symptoms. Thus, different literatures suggested that the psychotherapy and counseling during the rehabilitation is helpful for reducing this psychological hindrance of patient’s engagement in the rehabilitation process.

Enhancing self-esteem and self-management- Self-management is the key concept in the rehabilitation process. As in knee replacement surgery, patient temporarily looses independence; it also reduces patient’s self-esteem. Thus, the therapists should support the patient to be encouraged and be independent. For this, self-management skills should be taught (Levack, Kayes & Fadyl, 2010).

Educational health promotion- Patient must understand the importance of rehabilitation process in his life and its effect upon his working and independent life. In case of Mr. X, due to lack of proper knowledge, the negative pain perceptions were enhancing, reducing his compliance with the rehabilitation process.

Social support- Social support is another important factor that can facilitate patient’s engagement in rehabilitation. Social support can help to reduce patient’s isolation and can enhance self-esteem, thereby enhancing compliance with the therapeutic process.

While considering patient’s return to work after rehabilitation process, there are some other factors influencing their continuous recovery and adoption in the workplace. The most important factor is the occupational factors. Supporting the patient’s engagement with the recovery process, the employers and other employees should consider the patient’s condition and should help him to cope with the situation. It has been seen that, a patient returning to the workplace after a surgery, often treated as disabled person and sympathized, which hinders the patient’s emotional well being, because, an active person is being considered as a disabled or physically challenged person and discriminated from peers in the workplace (McPherson, Kayes & Kersten, 2014). This discrimination can lead to depressive symptoms, affecting his behavior. The patient becomes anxious and agitated, hindering his continuous recovery and returning to normal lifestyle.

To enhance Mr. X’s engagement with the rehabilitation process, theoretical models can be used for better understanding and strategy implementation. One renowned theory can be used here, the health belief model. The health belief model emphasizes on the perception of a person about the effect of health issues upon their lives and help to plan actions for helping patient’s engagement in health promoting activities. This model helps to predict and explain health behaviors, by focusing on the attitudes and perception of individual.

Figure: Health belief model

(Source: Mudge, Stretton & Kayes, 2013)

According to the health belief model, patients tend to compliance with the therapeutic procedure to prevent, screen for or control ill health, once they believe that they are susceptible to such a condition, that can have a serious negative impact upon their lives and a course of therapeutic action might be beneficial in reducing susceptibility or severity of the ill condition. Moreover, the patient should believe that the benefits of the action would outweigh the barriers. In case of Mr. X’s case, the health belief model is suitable because, it emphasizes on patient’s perception for negative consequences of not engaging with the therapeutic actions. However, for aligning the case with the health belief model, health promotion education is very important, which will make Mr. X aware of the pros and cons of the rehabilitation and its important in returning back to his normal life. In this context, his perception about pain and severity of his condition can be modified by his therapist’s support. In addition, the health education can modify his perceived benefits from rehabilitation and barriers of his engagement, which will be reduced by him once he is aware about all the facts (Mudge, Kayes & McPherson, 2015). From his perceived severity, threats related to non-compliance with the rehabilitation would be understood by Mr. X, which will encourage him to stay engaged with the rehabilitation process and adhere to the therapeutic actions. Engagement of Mr. X with a positive health behavior will stimulate his recovery, which in turn help him to get back his normal life in short period and return to his job. The health care professional has to change the perception of Mr. X that rehabilitation and embedded physical exercise sessions would enhance his pain, rather than giving him relief. Here, the therapist is solely accountable for encouraging Mr. to be aware of the fact that rehabilitation is the best way to get back to his normal active life, without any hindrance.

In addition to the health belief model, self-regulation theory can be used here, to enhance Mr. X’s engagement in the rehabilitation and recovery process. This theory can help people who are experiencing sickness behavior. The sickness behavior is one kind of behavior that arises during ill health condition, like Mr. X’s depression, anxiety and other related symptoms. According to this theory, a conscious personal management involves the process of guiding feelings, perceptions and behaviors to reach personal goals. There are four components of self-regulation, “standards of desirable behavior, motivation to meet standards, monitoring of situations and thoughts that precede breaking said standards and willpower” (Nieuwenhuijsen et al., 2006). The self-regulation model and its component can be used by the health care professional to motivate Mr. X towards rehabilitation engagement and enhancing his self-esteem and self-management skills to stimulate the rehabilitation process and returning to work.

Cognitive behavioral approaches- the cognitive behavioral approach include psychotherapy and behavioral therapies, which are helpful for Mr. X to be motivated and being engaged with the rehabilitation process. Here, the therapist should show dignity and respect to modify his perception about the rehabilitation process. In addition, these behavioral therapies will help Mr. X to control his psychological issues, which are hindering the patient engagement.

Motivational interviewing and therapeutic alliance- Motivating interview of Mr. X by his therapist and the employer can help him to be engaged in the rehabilitation process and cope with his working life after returning to his work. Motivational interviewing can help him to understand the importance of his rehabilitation process in his recovery and returning to his work. However, the interviewer should show respect and dignity towards Mr. X for providing value to his words and make a trustworthy relationship (Petrie, Jago & Devcich, 2007).  

Facilitating physical activity- Physical activity is one of best strategy to improve patient’s engagement and recovery process. Physical activity helps to enhance patient’s self-dependence, which is the key reason behind Mr. X’s depression and changed behavior. However, the physiotherapist should make him aware about the correct physical activity and the limit, which will give him relief, rather than increasing pain.

Health promotion- Health promotion is a key strategy that helps in enhancing patient’s awareness about the condition and recommended actions. Mr. X’s professionals were unable to promote his health outcomes due to failure in establishing a good relationship with him and due to lack of competence in making him aware of the benefits of the process. Thus, health promotion will help Mr. X to understand the importance of the compliance with the rehabilitation and change is perceived benefits and threats, thereby motivating his engagement (Siegert, McPherson & Taylor, 2004).

This assignment highlighted the case of Mr. X, who was suffering from severe pain and psychological issues after his total knee replacement surgery. The assignment highlighted some barriers including lack of motivation, lack of family support, lack of educational knowledge about the importance of rehabilitation and lack of therapeutic alliance, which hindered his engagement with the therapeutic processes and recovery. Here, with the help of health belief model and self-regulatory model, the factors that can influence his engagement by changing his perception towards his condition and benefits from the rehabilitation process have been highlighted. Finally, these factors has been emphasize to recommend strategies for practice, which included cognitive behavioral approaches, motivational interview and therapeutic alliance, health promotion and physical activity for enhancing his engagement and making him able to return back to his work.

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