Distinguishing theories of dysfunction, treatment and care. Reflections on 'Describing rehabilitation interventions'

Background: An editorial by Wade ( Clinical Rehabilitation 2005; 19: 811 - 18) suggested a method for describing rehabilitation interventions. Objective: To review the editorial critically, and to suggest a more complete theory. Editorial: The editorial develops a model identifying factors that should be considered when analysing a complex rehabilitation problem, and provides a high-level description of the rehabilitation process. It explicitly does not address theories of behaviour change. New ideas: Three additional theoretical models are needed. The first considers the mechanisms that link the factors identified in Wade's model. For example how does self-esteem ( in personal context) actually influence activity performance? This is a theory of dysfunction. The second needs to discuss how treatments alter their target. For example how does cognitive behavioural therapy alter pain perception and/or alter activity performance? This is a theory of treatment. It may be related to the theory of dysfunction. The third, which is less certain, needs to consider the process of giving support ( maintaining the status quo). For example, how should one offer continuing opportunities for meaningful social role performance to someone with major cognitive losses? This is a theory of care. Conclusion: The two models that Wade integrated in his conceptual framework ( the World Health Organization's International Classification of Functioning ( WHO ICF) and the rehabilitation process) should primarily be considered as descriptive in character. Theories are still needed to understand how activity limitation arises and how treatments alter activity limitation, and possibly how a patient is supported to maintain a certain level of activity