Figure 2: Framework for Stroke Rehabilitation
The "stage" column in the framework shows that physiological changes resulting from an underlying disease or injury may lead to impairment, which in turn may result in disability or handicap. In the instance of stroke, brain tissue is damaged from a lack of blood flow, which may lead to a limitation in normal functioning ability, e.g., memory loss or limited mobility. These impairments may result in a disability or handicap that constrains the individual's normal social role, e.g., by limiting capacity to work. This literature review does not distinguish between the terms "disability" and "handicap," although some literature does.
The "services" column of the framework shows that services differ according to the stage of the disabling condition. Continuing with the example of stroke, anticoagulant drugs may be administered to break up blood clots. Impairment may be addressed through such services as cognitive skills training for memory loss or use of a walker of physical therapy for limited mobility. In order to help maintain the individual's social role and functioning in the community, programs such as "Meals on Wheels" or technological adaptations in the workplace can address the disability.
The "context for services" column of the framework shows that rehabilitation services are provided in different settings and by different providers, corresponding to the stage of the disabling condition and type of services needed. For example, a stroke victim may initially present to the emergency room and be admitted to the hospital to be administered anticoagulants under supervision of a physician. As such, rehabilitation would differ little from medical intervention. Services to address the impairments of stroke may be delivered in a rehabilitation stroke unit of a hospital or in a residential nursing home, skilled nursing facility, or on an outpatient basis. Services to address the individual's social role are provided on an outpatient basis, and might include for example environmental modifications and transportation services.
It is notable that throughout health care, the context for service delivery has shifted; inpatient hospital stays are shorter as patients are managed in less intensive settings, moving from inpatient care to rehabilitative hospitals, skilled nursing facilities, or outpatient care. The growth of managed care and prospective capitated payment for inpatient health care has provided incentives to shift care from inpatient to outpatient settings, contributing to the increase in services provided in skilled nursing facilities, other ambulatory settings, and the home.