Skill Acquisition - A Model for Rehabilitation

Patty Scheets - Director of Quality and Clinical Outcomes

What is the ultimate goal of rehabilitation? We often describe rehabilitation as being about helping patients improve their function. And while this is generally an outcome of rehabilitation, I'd like to suggest that what we do is actually more precise. Quinn and Gordon suggest that the goal of rehabilitation is to help maximize a patient's skills or to promote skill acquisition. They define skill as being able to perform the activities of living with consistency, flexibility, and efficiency. Review the definitions of these terms in the table below and see if they resonate with what you do.

Consistency Performance over multiple trials or sessions
Flexibility Performance under a variety of conditions
Efficiency Performance with a certain level of energy expenditure


I think framing rehabilitation around the concept of skill helps us recognize and articulate the expertise we bring to a patient's care. While determining and improving a patient's level of functional independence is important, that alone doesn't really describe the decisions we are making in how we help the patient improve functional performance. Thinking about a patient's skills, reflects the quality of that patient's functional performance. If all we focus on is functional independence, we fall short of helping a patient reach his maximal potential. In fact, the ongoing questions we ask ourselves during a patient's course of care are, "Has the patient reached maximal consistency, flexibility, and efficiency with the things they want to do in life?" "Can I "squeeze out" anymore ability in any or all of those components?" Or, conversely, "Am I pushing for improvement in one or more of the components of skill and it's just not working?" For us to help patients reach their highest level of possible performance, we need to be experts at anticipating how much skilled performance each patient can achieve, "pushing" them to get to that point, while being realistic in our expectations. Being certain that we maximize a patient's consistency, flexibility, and efficiency with activity is what helps the patient not only achieve functional independence, but also reach critical thresholds related to reducing risk for falls, functional decline, hospitalization, and even mortality. It's a complex job, isn't it?

In recent meetings with the Directors of Rehabilitation, I shared some examples of language that we can use to describe the improvements in skills acquisition our patients are making as well as how to describe ongoing deficits in skilled performance. I've copied these for you below for your reference.

Improvements in Task Performance
Consistency
Because
- Larger/faster associated postural adjustments
- Larger/faster corrective postural adjustments
- Larger/faster protective postural responses
- Patient is getting stronger
- Able to maintain attention to primary task
- Allowing more time for movement preparation and planning
- Able to report intrinsic feedback
Flexibility
Because
- Demonstrating rapid access to best strategy for task
- Able to change strategy relative to situational demands
- Able to shift attention from one aspect of task performance to another
- Able to maintain primary task performance during performance of a secondary task
Efficiency
Because
- Improved vital sign response
- Decreased energy expenditure associated with fear or instability
- Decreased co-contraction in order to complete task or activity
- Improved speed of movement or performance


Ongoing Deficits in Task Performance
Consistency
Because
- Fluctuating medical condition limits opportunity for repeated practice
- Lack of intrinsic feedback to guide performance
- Performance within a session improving but needs further practice for learning
- Deficits in timing or movement amplitude which are changing but still insufficient for all tasks
- Deficits in timing or movement amplitude which are not changing with practice
- Weakness which is improving but will require ongoing resistance training
- Weakness which is not responding to treatment
- Deficits in placement of attentional resources
- Agitation which limits opportunity for repeated practice
Flexibility
Because
- Fluctuating medical condition limits opportunity for repeated practice
- Lack of intrinsic feedback to guide performance
- Inability to develop effective strategy without extrinsic feedback
- Fear or anxiety with new activities
- Agitation which limits opportunity for practice
Efficiency
Because
- Fluctuating medical condition limits opportunity for repeated practice
- Primary health condition limits practice for extended periods
- Poor prognosis for improvement in impairments


Let me know what you think of this concept of rehabilitation and promoting skill acquisition. Feel free to contact me at PLScheets@InfinityRehab.com .
Patty Scheets - Director of Quality and Clinical Outcomes.