Not All Rehabilitation is Physical Therapy

When we are faced with problems that have arisen or are secondary to a particular pathology, the first thing that comes to mind is that we should go to the psychologist, social worker or physiotherapist, but what about functionality and personal autonomy? How can this influence our daily life activities? The occupational therapist, unfortunately little known or undervalued, plays an essential role in this type of situation and especially in work with the elderly.


Introduction
During the last few years, Gerontology and Geriatrics have experienced a great impulse from both classical research and the growing interest in the processes of population ageing in the search for quality of life and personal independence in the last phases of life [1].
Cognitive abilities or skills such as memory, evocation or recovery of information (sensory, short or long term) or contrary as the loss of efficiency in the performance of the activity, secondary to any of the functions mentioned above, can cause further deterioration of the subject that reduces both the quality of life and their level of autonomy [2].
Active ageing as we know it today emerged in the sixties and seventies with a focus on life satisfaction related to the activity people were carrying out, requiring new roles to compensate for those lost and in turn a feeling of being active and participating in society [3].
Starting with the preparation of a patient profile, gathering as much information as possible from family members, the user and other professionals, we complete what we call an occupational history. This history provides us with information about the patient's lifestyle, interests and evolution, which allows us to identify the activities that are most appropriate for the patient's condition and tastes, with the aim of involving the user during the treatment or operation in order to maintain both their attention and their predisposition towards the objectives previously set, whether these objectives are established or agreed upon with the patient.
Taking into account that multipathology, common both in this type of population either by age or symptoms, usually accompanies the geriatric population, achieving greater independence or autonomy prior to the current situation is a difficult task, since the body's own systems are not as they were in years or states prior to the current one, so in some cases it is only possible to partially recover the systems or alleviate this deficit with the use of external tools or support products that allow users to bridge the gap with their previous state, allowing them to perform the activity in the most standardized way possible [5,6].
The training and adequacy of an adequate care team is key to offering an optimal comprehensive geriatric service, which allows the realization and design of an appropriate and personalized intervention plan according to the characteristics of the user. The difficulty of intervening in a geriatric patient requires the inclusion of different disciplines that can complete all the areas in which the patient may present some type of problem (physical, functional, psychological and social).
The fact that the multidisciplinary team is an important part of the user's approach allows us to identify different points of view on the same areas of intervention, being able to exchange information and work towards a common goal [7].

Occupational therapy and activity
According to the World Federation of Occupational Therapy (WFOT), occupational therapy is defined as a profession that promotes health and well-being through the use of occupation as a means. The main objective is to encourage people to become independent in their activities in order to improve their participation. These activities allow the user to increase the independent functions that he or she maintains, enhance development, prevent disability, and improve independence and quality of life [8]. Through this objective, it allows the development of performance components necessary to carry out the activities without problems based on the therapeutic use of the activity with purpose during the intervention process [9]. Therefore, occupational therapy can be understood as the profession that deals with through a meaning or directed to a purpose, with the activity as a base, evaluate, facilitate, restore and maintain a function. Depending on the objectives set by the occupational therapist, it can provide the means to enhance strength, promote social action, stimulate cognitive functions, etc. [10] (Figure 1).
The activity is a set of actions carried out with the aim of meeting the goals of an operational program. It consists of the execution of processes and tasks, using certain human, economic and material resources assigned to the final activity.
Such action must maintain or contemplate a meaning for the individual or a feeling of competence that will be important to engage the user during the therapeutic process and thus produce positive feedback.
On the other hand, the activity (meaningful for the user) can be graduated or adapted to facilitate or promote the full implementation of the activity [11]. Depending on the focus or direction you want to take on the type of activity to be used, level of demand or qualities needed to carry it out, so during the previous design a challenge will be proposed that is sufficiently important to motivate your positive participation in the activity.
Associated with the sense and meaning that human activity should carry about emotional well-being, Csikszentmihalyi proposes a different way of understanding activities adapted to the different capacities of people, providing that sensation of flow or letting go, thus giving birth to the "Flow Theory". This emotional experience after carrying out the activity allows to report during the participation a positive and pleasant feeling while carrying out [12].
This theory is developed around the search for optimal user experiences during the performance of activities, based on previous experience, skills and abilities in a balance between the possibility of realization and the ability to act of the subject. This level of challenge or demand for the activity must be appropriate to their capacities/skills, encouraging, as mentioned above, their participation, promoting positive feedback and a balance between the patient's demands and skills.
Happiness is defined as the basis of the quality of life of people, but it also requires what one does to be happy, developing goals that bring meaning to our lives, giving a feeling of satisfaction for something well done through the construction of one's own goals, development of potential, intrinsic motivation enjoying the performance of the activity and motivation in its completion [13]. On the other hand, this lack of time or feeling causes adverse feelings such as stress, increased social concerns or even decreased physical and mental health. Update in Geriatrics 4 The Flow Theory cites the conditions in which an activity can be considered therapeutic, which are when commitment and concentration are allowed and the user has the necessary tools to carry it out.
Another theory related to the application or use of activities is the DOiT Model (Dynamic Occupation in Time Model) developed by Larson. This model proposes a continuous development of the activity and its skills related to the passing of time together with the subjective experience (Well-Being). The dynamic participation of the therapists in the selection of the activities allows to suggest different forms and strategies of approach, looking for the most positive experience during the time of accomplishment (Figure 2) [14].
A greater commitment in developing activities will awaken a feeling of competence, causing a diversion of your energy towards those things in which you show the greatest interest, the greatest need and therefore the search for feedback after completion.
This commitment is generated once the patient actively participates in the activity, Flaherty [15] proposes that some activities provoke an emotional response or interest that leads to commitment, but at the same time these are influenced by their capacities and abilities, past experiences, etc.
If we base ourselves on what Flaherty mentions, quality of life is a determining factor in the individual's interest in participating, in the emotional response and in the level of commitment to the activity.

Activities of daily living
Activities of Daily Living (ADL) are those tasks whose purpose is personal self-care with the greatest autonomy and personal independence of the patient. This capacity allows the user to choose or decide for him/herself by making effective use of the freedom [16].
The term coined by the American Occupational Therapy Association (AOTA) brings together all those activities that a person does from the time they get up until they get back up the next day such as: self-care, productivity, leisure and free time. As specified by Romero-Ayuso [10] "Activities of daily life encompass the most frequent activities performed by a subject, they are related to the familiar, daily, every day, human needs, independence and use of time. Depending on their cognitive complexity and purpose, towards oneself or in relation to the environment, two levels have been established: basic activities and instrumental activities of daily life. The origin of this classification already refers to the importance and need to contemplate the cognitive processes underlying the activity" If to all the above we add the aging process, some pathology, the difficulties to maintain that optimal level of autonomy from that moment on increase, so health professionals must focus not only on the disease itself, but also on the repercussions associated with the pathology and the forecast, in order to anticipate and maintain the quality of life of the elderly [17].

Psychosocial aspects associated with ageing
Much research highlights aspects that are often associated with older people who are not really older, such as deficits or impairments related to physical or cognitive abilities. The concept associated with active aging defends the opposite, allowing them to maintain healthy and preventive aspects showing a great quality of life that allows them not only to live in their natural environment without problems but to develop as people with identity, roles and maintaining the realization of activities that they usually do in their day to day [18]. On the other hand, it is essential to show the people we work with, in this case older people, why they should carry out these productive or meaningful activities for them, what they can achieve and how it will help them to develop their daily activities in an autonomous and independent way (Figure 3).

The personality
Personality plays a fundamental intrinsic role among the psychological aspects that can influence people to a great extent since, depending on the way they respond, they will carry out the proposed activity in one way or another.
There is an important relationship between activity and life satisfaction, connecting or disconnecting from society as a result of low mood, poor adaptation and other similar emotional disturbances [18].
A peculiarity about the García & González studio [20], is the classification of two groups of people who were more likely to remain active throughout the end of their lives than the other group who showed a tendency to retire early and express a desire to disconnect socially and professionally.
The fact of being active as a formula to maintain personal identity allows and helps the user to enjoy and value positively the time spent, the performance of functions and the promotion of a correct state of mind in this respect.
On the other hand, finding a meaningful activity suitable to one's tastes and personality allows to improve the sense of life, directly affecting the perspective of life, bringing happiness and investing that time in those roles in which they were happy and improving the adaptation of those who remained committed and connected during the last part of their lives [21].

Psychological well-being
Psychological well-being is defined as the balance between expectations, hope, dreams, achieved or possible realities, expressed with satisfaction and the ability to face vital events in order to adapt [22].
Ryff defines psychological well-being as a multidimensional construct subjectively perceived by the individual defined by the meaning and significance of life for oneself [23].
There are five aspects or areas of psychological well-being: • Self-acceptance.
• Formation of positive relationships with others.
• Formation of autonomy.
• Mastery of the environment.
• Purpose in life.
Consistent with well-being is self-acceptance, understood by Ryff as the positive attitude towards oneself and one's past, positive relationships as the ability to maintain close relationships with other people, autonomy as self-determination or the ability to make decisions for oneself, mastery of one's environment as the individual's ability to create or choose favourable environments to satisfy needs, purpose in life to provide life with goals, objectives and meaning, and finally purpose in life related to one's potential and personal growth (Figure 4).

General self-efficacy
A term introduced by Bandura that captures the way one feels, thinks and acts associated with thoughts or as a set of beliefs in one's own abilities to organize and execute actions required to produce achievements or results [24].
In a study on self-efficacy and self-esteem in the Chilean population, the lack of activity was a determining factor in low self-efficacy in young people between 18 and 25 years of age, between 26 and 64 years of age maintained optimal levels of activity and mastery over the performance of roles when they were working, and from 65 years of age onwards after leaving work, it led to greater vulnerability to negative feelings, low social competence and a decrease in personal well-being [19,25].
Buendia indicated that those older people who unilaterally and voluntarily reduce their social activity by accepting less intense roles and focusing on their inner self, deprive them of a multitude of emotional, physical and financial supports important for their continued personal development [26].
Perceived self-efficacy allows the user to obtain the skills necessary to conclude the desired results with respect to the activity. However, those with higher motivation may choose to undertake activities that are more difficult than those with low motivation, requiring more effort and requiring a sustained commitment.

Environment and personal independence
One of the most neglected and fundamental factors in the geriatric population is the environment, which can exponentially increase the physical possibilities of the user or increase their inability to carry out an activity, reducing their personal autonomy, a key factor in this population. On many occasions these impossibilities are developed due to the individual's life situation, acting as a barrier to normalized functioning. These excessive incapacities can become real incapacities, weakening the person and accelerating their physiological decline.
A study by Summers allows us to know through non-pathological factors how the role of a psychologist can be decisive in the intervention of functional impairments in the last part of life [27]. This study concluded that the psychological state of the person is a predictor of the degree of disability that the person experiences, taking into account [28].
On the other hand, Rodin [29] in a residential care home for older people carried out a randomized working group distribution based on power of choice and opportunities at a conference. After the conference they were encouraged to accept responsibilities, planning tasks, maintenance of facilities, etc. The other participating group was encouraged to attend talks on attitude, personal assistance, care and personal hygiene.
The results showed that the first group as opposed to the second developed signs of happiness, increased activity, responsiveness, stress reduction, as well as more commitment to the activities offered at the center itself.
If we look at other types of studies such as the one developed by Cummings [30], the passage of age implies a progressive disconnection from the social group, distancing oneself from society and coming to see oneself as a natural part of the ageing process [31] (Figure 5).

Conclusions
If the characteristics of the people are added together with the possibilities that the environment implies, it can generate or promote a level of activity over the older  [16,32]

Author details
Abel Toledano-González Psychology Department, Faculty of Health Sciences, University of Castilla La Mancha, Talavera de la Reina (Toledo), Spain *Address all correspondence to: atoledanogonzalez@gmail.com adult, allowing to give sense to variables or psychological aspects in an intrinsic or extrinsic way in a positive or negative way against a stimulus or activity adapted to their characteristics [33].
Factors such as psychological well-being as a way of accepting oneself and developing one's own potential for personal growth and capacity to face life events, together with self-efficacy as a way of motivating performance, can increase both physical and psychological possibilities in the field of geriatrics.
Finally, as the title of the chapter shows, not everything is physical rehabilitation, since other factors associated with the person must be taken into account, which can play an important role, not only in the predisposition towards a treatment or intervention, but also in the normal development of his/her day-to-day life.