1. What is reiki?
Reiki is a technique for channelling energy from the universe into a person, object or event through placement of the hands. Some believe it was developed in the early 1900s[1]. Others believe that it was revealed from meditation on ancient Sanskrit sutras[2]. A woman named Hawayo Takata is credited with introducing reiki to the West[2]. According to her, reiki was invented by a Christian boys’ school headmaster named Usui Mikao[3], but according to cynics this story may have been contrived to facilitate the marketing of reiki to Christian people in the West[2]. Others believe that Usui was a Tendai Mikkyo Buddhist, influenced by Shintoism and Shugendo[4]. Unfortunately until recent times reiki teachings were conveyed only by word of mouth. It is therefore likely that the techniques and story have been modified several times by people to suit their own needs and religious or political interests. It may therefore not be possible to determine where reiki actually came from.

2. Before I experienced reiki:
As a junior physiotherapist I was scientifically minded to the point of being sceptical about many physiotherapy modalities. I had seen enough inequity and injustice to turn me to atheism. I worked weekends for Britain’s nuclear, biological, chemical regiment, to prove my British identity and express aggression in a socially acceptable way. I consumed tubs of ice cream or family-sized cheesecakes on a daily basis and accompanied colleagues to the pub across the road every day after work to relax myself with stout. A couple of male colleagues and myself used to have regular letching competitions during which we would each try to find the most attractive woman to look at. Unbeknown to me, a chance meeting was about to start a chain of events that would change all of this.

3. My initial experience of reiki:
A woman I met socially told me about reiki and offered me a demonstration. She moved her hands over me without touching me, and as she did so I felt waves of energy pulsating through my body. To my amazement, she told me things she intuitively knew about my military injuries. I thought this would be a great skill to have as a physiotherapist, so I asked for her teacher’s contact details and booked myself onto the first available lesson.

4. The first attunement:
The first lesson took just one day. The reiki teacher spoke of angels and how reiki would change our lives. I thought she was away with the fairies. She told the students that reiki was taught through a series of attunements, each of which would be followed by a detoxification period during which we could feel ill as our bodies became accustomed to a higher energy flow. After a brief ritual she blew into my hands. From that moment my palms were tingling and warm for no apparent rational reason. We spent the rest of the day practising reiki on each other and most of the students were able to find each other’s illnesses and injuries by feeling the energy alone.

On returning to work, I wondered whether I had imagined the whole thing, but as soon as I walked onto a ward my palms started tingling. Practising on patients was out of the question, but one of the senior physiotherapists had a migraine and allowed me to try reiki on her. She said it worked, but I found it very difficult to believe. Similar incidents would soon occur with several other clinicians, but I remained unconvinced. Events did not fit with my understanding of science and I wondered if my colleagues were teasing me when they said the reiki worked. At the pub after work my hands felt repelled by an unseen force around a pint of stout and a strong sense of intuition told me not to put chocolate cake in my mouth.

5. The detoxification:
Over the next month I re-experienced childhood knee pains, digestive problems, asthma and had a terrible cold. According to the reiki teacher these things were significant messages about problems with my life. This theory was just another aspect of reiki that I was not prepared to believe. With time however I came to accept that my childhood abdominal problems were due to a lack of power and social status. My asthma and heartburn were due to inhibition of my love, and my perpetual colds were due to poor awareness of my own intuition[5]. I would come to understand this theory as somatic metaphor. It brought me awareness of the huge untapped potential for occupational therapy. I just needed scientific evidence to triangulate the belief. I was still unsure whether reiki was real or just a figment of my imagination.

6. Learning to use reiki:
I learned to use reiki through experience. The results did not cease to amaze me. Feeling people’s energy provided me with indications of what their psychosocial problems were according to the theory of somatic metaphor. Lifestyle change proved to be far more effective for resolving chronic energy problems than the reiki treatment itself.

7. Progressive attunements:
I went to my second attunement with an occupational therapy manager I knew. The attunement was to an energy called seichem. We were taught a psychic surgery technique that involved liaison with celestial beings. I did not believe in such things, but went through the motions and was shocked to feel an unseen being placing unseen objects in my hand. Several experiences during the surgery did not fit with my understanding of science and I thought I was imagining them until the occupational therapy manager described the exact same events in a way that she could not have known that I had experienced them. My rational mind searched for explanations. Had we been drugged or hypnotised? Was this some form of mass hysteria? As I progressed through four other attunements over the next nine months my paranormal experiences became progressively more vivid. After my final attunement I went on to teach several doctors and a student nurse. Conducting attunements myself was an overwhelming experience. I perceived brilliant light radiating out from inside my body and saw angelic beings for the first time.

8. Progressive breakdown of my reality:
I became aware of sensations that other beings were around me at various times during the day. At first I could not see them but could feel their presence. I became sensitive to other people’s feelings to the extent that my emotional state varied to match that of people in my proximity. Over time I would learn to distinguish between other people’s emotions and my own. I remember going to my pigeonhole at work one morning and wondering whether I had developed schizophrenia. I was experiencing what Collins[6] recently described as spiritual emergency. As my training progressed, my psychosocial problems manifested metaphorically as visible and tangible demons. My intuition told me the meaning of each demon, and what I had to change about my life to leave it behind. The natures and significance of each demon were personal and will therefore not be described in this blog. For my masters’ attunements I was taught how to teach reiki and attune other people. During this lesson I discovered that reiki teachers (from the Tera-Mai lineage) do not actually attune their students, but call on celestial beings that do it. I was unable to believe in such beings until I started teaching reiki myself, and experienced direct contact with them. At this point, the logic I had based my atheism on no longer seemed valid.

9. Ethical problems:
A senior occupational therapist once told me that Jesus is the only source of spiritual healing and therefore reiki must be a trick of Satan. During a lunchtime discussion one day, fellow physiotherapists ridiculed the concept of healing energy and expressed that the idea of occupational choices profoundly influencing health was ludicrous. I was not aware of any published data to support evidence-based practice. The Royal College of Nursing once approved a reiki course for the continuing professional development of nurses, but subsequently withdrew their approval due to their interpretation of a House of Lords report on complimentary therapies[7]. For these reasons, I have never been able to use reiki with National Health Service patients. Some time later, I was presented with two subjects that seemed to have serious energy problems. One had an energy imbalance down one entire side of his body and the other seemed completely deplete of energy. Neither had any awareness of having health problems. I therefore said that there was no evidence that what I was feeling meant anything and it should not be a cause for alarm. After this event I stopped practising reiki because I thought it could worry people unnecessarily. Within a year I was shocked to find that the first subject had a hemiplegic stroke and the second had died of cancer. Diagnosis had been made too late for life-saving treatment. I had a few sleepless nights after receiving this news, before deciding not to start practising reiki again, except for with spiritual aspirants that requested it specifically to facilitate spiritual emergence. I believe that great care should be taken when selecting reiki students, to ensure that they have the emotional resilience to endure spiritual emergencies without developing mental health problems.

10. How reiki changed me:
Reiki inspired several changes in my life. Much to the bemusement of my friends, I gave up alcohol and letching at women. Specific decision-making is often informed by reiki. A memorable example of this was an attractive woman flirting with me and kissing me after a formal army dinner. I felt a very strong force pushing me away from her as though an invisible person had put his palm on the side of my head and was extending his arm. At the time I thought her guardian angel was protecting her from my amorous intentions. I therefore concluded my behaviour was immoral and I left her alone. Later that night I noticed her tendency for attention-seeking and somebody that knew her well told me she was pregnant. Perhaps I was the one that was being protected. On a wider scale, I was unsure of the ethics of the invasion of Afghanistan, but previously ignored this because I enjoyed soldiering so much. As a manifest demon, this dilemma was impossible to ignore, so I transferred to the Medical Corps to ensure that I would never be ordered to kill. My new sensitivity also convinced me to leave unethical jobs in Council Housing and National Health Service management. My experiential knowledge of somatic metaphor convinced me of the importance of occupational therapy[8]. If demons could be real I reasoned that God could too. This inspired me to read the Bible, Koran and various other religious texts that have restored my faith in God and helped me built rapports with patients of each book’s respective faith. The fact that lifestyle change is more effective for restoring energy balance than reiki itself is an indication to me that occupational therapy has the potential to make reiki obsolete. Reiki inspired me to analyse evidence of occupational influences on health[9, 10] and ultimately re-train to be an occupational therapist.

11. Possible implications:
The paranormal experiences resulting from reiki led me to wonder about the functions of hallucinations and whether or not these are always pathological. Perhaps people should only be considered ill if their hallucinations adversely affect their happiness or social functioning. Shamanism is common to several cultures, and though Western science currently tells us to disregard it, there may be a hidden science underlying it. Some occupational therapists have argued that “there is still a need to understand better the impact that spirituality has on health and wellbeing”[11]. Perhaps reiki training is a suitable method for occupational therapists to gain experiential knowledge of this. In some cases, responding to or interacting with hallucinations might change an individual’s life for the better, while ignoring them or medically suppressing them could prove detrimental. An example of this has been documented in the British Medical Journal. A woman was alerted to her brain tumour by a voice telling her a) that she had one, and b) which hospital in her locality had a suitable magnetic resonance imaging (MRI) unit. Responding to the voice she managed to convince her general practitioner that she needed a MRI scan, and was therefore successfully diagnosed and treated[12]. If medical treatment had been focused on suppressing this lady’s auditory hallucinations, the brain tumour would not have been diagnosed as early.

12. Summary:
Modern reiki is a healing energy technique of uncertain origin. I do not believe it is a suitable modality for occupational therapy. It has however been offered by non-occupational therapy staff in National Health Service Hospitals[13] and could be a great personal development tool for occupational therapists that wish to accelerate their own spiritual emergence, or would like to experience a different perspective on how occupation can influence health. The evidence for this is intra-personal. This blog entry only briefly touches on my experiences of reiki, and I only trained with one of many reiki lineages. Further reading is therefore recommended. As scientists I expect graduate occupational therapists to have a healthy cynicism about reiki. I suggest that anybody that doubts reiki or the existence of a spiritual plane should take the six reiki and seichem attunements up to masters’ level to inform their judgment before making up their minds.

13. Recommended reading:
Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
Paul N.L. (2005) Reiki for Dummies. Hoboken: Wiley
Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books

14. References:
1. Stevenson M. (2003) Brief introduction to Reiki. British Journal of Therapy and Rehabilitation 10(1):34
2. Shealy C.N. (1999) The Complete Illustrated Encyclopedia of Alternative Healing Therapies. Shaftesbury: Element Books
3. Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
4. Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books
5. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3): 8-10
6. Collins M. (2007) Spiritual emergency and occupational identity: a transpersonal perspective. British Journal of Occupational Therapy, 70(12):504-512
7. Manson C. (2003) A brief introduction to Reiki. British Journal of Therapy and Rehabilitation 9(9):368
8. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. Available at: http://www.metaot.com/blogs/%5Buser%5D-6 Accessed on 24.3.2008
9. Mailoo V.J., Williams C.J. (2004) Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 11(1):7-12.
10. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11):503-510
11. College of Occupational Therapists Ethics Committee (2001) Addressing spiritual needs. British Journal of Occupational Therapy 64(2):107
12. Azuonye I.O. (1997) A difficult case: diagnosis made by hallucinatory voices. British Medical Journal, 315:1685-86
13. Mehrfar M. (2006) Patient Healing comments. Available at: http://www.cancertherapies.org.uk/patient.php?PHPSESSID=ca4dc83f058d6a7f... Accessed on 28.6.2008

Examples of it’s potential rehabilitative qualities include ‘77-year old Jerry Pope, a former semi-pro tennis player. Following his stroke in June, he’s been using the Wii Tennis activity of Wii Sports and swings of the Wii Remote to help regain movement in his hands and feet, along with his balance’

He claims the Wii “is extremely motivational and gives you the illusion that you’re progressing even if you’re not, putting you in a better frame of mind”.

An opinion piece by Verdonk and Ryan ( 2008 ) asserts that occupational therapists ‘can, and should, capitilise on the opportunities offered by mainstream technology’ within everyday meaningful occupations as potential therapy tools and for use in practice environments. They suggest that technology ‘offers therapists new types of handiwork and enabling devices’ and that both occupational therapists and occupational therapy departments ’should reflect these changes and consider exchanging therapeutic cones for computer and video games consoles’.

The use of computer games in therapy appear to multi-faceted. Not only (in my opinion) are they more enjoyable and stimulating than for example the use of the therapeutic cone, their multiplayer options can be used to encourage group therapy sessions. As suggested by Verdonck and Ryan ( 2008 ) ‘competition can be an intrinsic motivator or it can be a pain distracter and increase tolerance for occupational therapy sessions’. Who knows, perhaps the next PlayStation will be able to cure cancer?

Another example of the implications of technology within the field of occupational therapy lies with the use of information and communication technology. Verdonck and Ryan ( 2008 ) demonstrate an interpretation of the Canadian Model of Occupational Performance to mainstream technology using the internet. They state that the internet ‘can be considered a virtual environment in which the person can engage in occupation’. An example is: Self care through the use of online shopping; Leisure through the use of music downloads; and Productivity through the use of buying and selling online. It is clear that the internet plays a huge role in not only improving the quality of life for those who may have limited access to their communities but also plays a huge part in facilitating functional independence. With a potentially more technologically savvy older population, is it likely that hospital assessments may eventually incorporate the persons ability to use the internet as a factor in their safe discharge home?

Please see my blog: otlondon.wordpress.com

ref:
http://www.dailymail.co.uk/health/article-486525/Wii-games-help-stroke-v...
Verdonk and Ryan (June 2008)Mainstream Technology as an Occupational Therapy Tool: Technophobe or Technogeek? BJOT

2. Relevance to occupational therapy: Here are a couple of examples of non-holistic service being delivered in the guise of ‘occupational therapy’:

“I work in acute orthopaedics. I have been told due to budgetary constraints my role is only to ensure safe discharge from hospital. I have previously been criticised for improper use of resources when I dealt with quality of life issues.” [1]

“….one of their team leaders told me community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation.” [2]

How do you think this kind of practice is affecting the professional and public images of the occupational therapy profession?

3. The consequences: I recently heard that in one acute setting, physiotherapy has been funded for cardiac rehabilitation but occupational therapy has not. Could this be because the funding authorities have no idea what occupational therapy is, due to the various confusing images we have collectively portrayed while working in reductionist ways? [3] Here is another example of where our profession seems to have lost out due to failure to project a clear image of its remit and potential:

“The Primary Care Mental Health Team told me that they no longer have any occupational therapists on their staff. The woman I spoke to said that even when they did have occupational therapists, they did not provide an occupational therapy service, but worked generically. She actually said "we provide mental health-care; not occupational therapy". I asked her how it was possible to provide mental health-care without occupational therapy, but this question just went over her head.” [2]

Our profession is losing out to other competing professions due to failure to maintain a strong professional image.

4. Conclusion: Perhaps we should change our job titles when not practising holistically. This would prevent non-holistic practice (due to constraints set by public service management) from tainting the image of our profession. Discharge facilitators should simply be called 'discharge facilitators' and the social services team leader who thinks “community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation” [2] should consider re-naming her team ‘the ergonomic adaptation team’ or something similar without the words ‘occupational therapy’ included.

V

5. References:
1. Basic grade (2008) Somebody please help me. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2289
2. Venth (2008) reality check. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos...
3. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

“Preventive measures are less expensive than the restorative measures” (Clark 1992, Friedland et al 2001, Hajnal 1997, Sheiham 1992).

Introduction
The article will define health promotion first and than will look into upstream thinking. The importance of health education in health promotion, along with different types of health promotions will be discussed. Health promotion on a wider perspective will be explored and will be related to rehabilitation. Finally the article will discuss change of health behaviour using health promotion model. The aim is to gain understanding of health promotion for the rehabilitation professional in order to incorporate them into rehabilitation practice.
An analogy of upstream thinking.
McKinlay(1979) analogy of a man standing by a fast flowing river who spent his time jumping in and pulling out people who were drowning. The task of jumping in, pulling them to the shore and applying artificial respiration was so demanding of his resources that he had no time to go upstream to prevent them falling (or being pushed in the river). The story introduced the notion of refocusing upstream and of upstream planning and action.

Defining Health Promotion
Health promotion can be described as the process of enabling people to increase control over and to improve their health (WHO, Ottawa Charter 1986).Ennis et al (2006) describe health promotion activities as behavioural, cognitive and emotional endeavour to promote health and well being of people. It is a multidisciplinary endeavour taken up in diverse setting (Scriven et al, 2004).

Education in Health Promotion: Primary Health Promotion activity
Enabling people by empowerment was emphasised as being a part of health promotion process (Gottwald, 2006). In a systematic review, McDonald et al (2004) found in nine studies involving 782 participants from a pool of 17 potentially eligible studies, the evidence that preoperative education prior to hip and knee replacements, reduces anxiety. The review included only randomised studies which could be seen as its limitation, as inclusion of other rigorously completed studies could have increased the sample size. But empowering people by education is not just health promotion (Davis, 1995 and Gottwald, 2006). In a randomised controlled trial Ennis et al (2006), found health promotion education for multiple sclerosis to be effective in increasing level of health promotion activity undertaken by patients, confidence and belief in ability to undertake health promotion activity as well as certain domains of quality of life. Although the limitation of the study can be seen in its sample size, as it was completed on sixty two adult multiple sclerosis patients. In another randomised controlled trial, Almomani et al (2006) found in a treatment group of twenty patients that dental hygiene instructions along with dental education and a mechanical toothbrush, had a positive effect. The control group was provided with mechanical toothbrushes, in a cohort of fifty mentally ill patients which included schizophrenics, bipolar disorders and other mentally ill clients. The generalisation of the result however can be argued as patients were only followed up once in four weeks and that the study was completed with fifty patients. However the two studies highlight the importance of education in health promotion. But health promotion is not just empowering people by education (Davis 1995 and Gottwald 2006). It is a much broader concept.
Scriven et al (2004) described “Primary health promotion activities” as upstream activities that target the well population. The goal is to prevent illness and disability by health education (targeting lifestyle and behavioural change) and/ legislation (Such as the smoking policies).

Health Promotion: A wider perspective
Davis (1995) in a qualitative study identified that nurses use health promotion and health education in neuro rehabilitation. The research resulted in the development of a model in which policy making, social and physical environment were all considered as health promotion activities. Empowering patients and working with them to make them independent (clients being the co manager of their conditions) was considered as health education. The study was completed rigorously although the ethical considerations and the data analysis could have been more explicit.
Health promotion includes wider perspective like consideration of social environment, preventive health service, community based work, public health policies, environmental health policies, organisation development, economic and regulatory activities (Gottwald , 2006). Scriven et al (2004) described “Secondary health promotion” is directed at individuals or groups in order to change health damaging habits and/ or to prevent ill health moving to a chronic or irreversible stage and where possible to restore people to their former state of health and/ or community development approaches that encourage structural and environmental changes. The “Tertiary health promotion” takes place with individuals who have chronic conditions and /or are disabled and is concerned with making the most of the potential for healthy living (Scriven et al 2004). These might include client centred approaches, such as those used in rehabilitation, or the management of chronic disease programmes. The therapists currently in United Kingdom (UK) work as the secondary or the tertiary health promoters and hence the emphasis is to work as the primary health promoter, yet that would need a paradigm shift altogether (Scriven et al, 2004).

Health promotion in Orthopaedic or surgical Occupational Therapy Practice
Occupational Therapists see patients in the pre-admission clinics or do pre-operative home visits, before they come in for total hip replacement surgeries. These activities can be seen as “Primary Health Promotion” as the aim is to prevent post operative complications (Most common of which is the hip dislocation). The assessment and intervention includes discussing/ assessing home situations, assessing baseline functioning, providing equipment to assist in ADLs, problem solving patient issues (addressing anxiety of the surgery), addressing sexuality issues for the post operative period and also referring to the other multidisciplinary team members. These activities can be clustered as primary health promotion activities as the aim is to prevent illness or disability.
Therapists see amputee patients immediately post operatively. The empowering process post operatively can be viewed as primary health promotion as it helps patients’ to be better compliant for the forthcoming therapy and helps them to accept their disability, although this can be argued as tertiary health promotion as interventions are following disability caused.
The Occupational Therapists see patients following hip/ knee replacements in hospital wards. They address their home situation, discuss precautions with the operation, assess home environment, check mobility and transfers following the surgery and refer patients to the community team for follow up. These activities can be clustered as “secondary health promotion”, as the aim is early detection of problems and to address them in order to prevent future disability. However therapists in hospitals/ community who work with patients with recurrent hip dislocations can be viewed as “tertiary health promotion”, in the area of practice. Hence Occupational Therapists in order to promote upstream thinking should assess patients pre-operatively. This does not necessarily rule out the need of Occupational Therapists in the wards, but Physiotherapists can contribute to secondary health promotion, in the area of practice. However the roles of Occupational Therapists and the Physiotherapists are indispensable in order to manage trauma patients (admitted following dislocations) for tertiary health promotion.
When rehabilitating the amputees, adapting the home environment and prosthetic rehabilitation can all be viewed as tertiary level health promotion (as the patient is permanently disabled following amputation). Empowering amputees from time and regularly following them up in outpatient/ community can also be seen as secondary health promotion activities. Hence for amputees the process of empowering, environmental adaptations, prosthetic rehabilitation and regular follow up, contributes to health promotion.
Understanding Health Promotion in Rehabilitation: An Overview.
Apart from education, other examples of preventive health service or community based work which can be viewed as upstream working by therapists, can be extrapolated from the rehabilitation of elderly patients in the General Practitioners’ surgery. Time up and Go test (TUG) is an outcome tool for falls assessment in rehabilitation. In a pilot study, Dinan et al (2006) found of the two hundred and forty two patients referred for exercise classes at the GPs surgery, one hundred seventy eight completed cycles of classes. The TUG scores were obtained at the baseline and at follow up. TUG values showed reduced risk of fall for these individuals in the community implicating beneficial effect of the exercises although the sample had more females than male adults. In a randomised controlled trial, Rosendahl et al (2006) found similar positive long term effect of high intensity functional exercise programme in balance, gait ability and lower limb strength for older people dependent in activities of daily living (ADL). Another example of community based work and health promotion is the motivation to volunteer. Black et al (2004) found volunteering to have beneficial effect in mental wellbeing of the elderly population. In an Adult Health Development Program (AHDP), when students from various disciplines (including nursing students) were being paired up with adults to engage in several health promotional activities, it was found to have beneficial effect (bi directional). The activities included health education hour, low impact exercise group, swimming and water aerobics, weight training, trampolining, billiards, Tai chi, walking, three wheel biking, dancing, parties, celebrations and socialising with friends. This was termed as Transgenerational Health Promotion by Watson et al (2000), as students learnt about the ageing process and the program helped to improve health and wellbeing of the adults. This can be viewed as another form of community working in order to promote health and wellbeing. Health promotion in rehabilitation can also be understood by group work called “Problem based rehabilitation”. It is an active group work where the group members discusses and facilitates by problem solving and by providing psychosocial support for each other. Medin et al (2004) in a case study with disabled people on long term sick leave from work found problem based rehabilitation to have positive effect to help people return to work and also to improve self esteem, without making any generalisation of the finding.
Thus health promotion and rehabilitation are linked very intricately. Change of models of health promotion.

Health behaviour change using health promotion model.
Health behaviour change was defined as “the shift from risky behaviors to the initiation and maintenance of healthy behaviors and functional activities and the self management of chronic health conditions” (Nieuwenhuijsen et al 2006). Health promotion can be achieved by understanding individual “locus of control”. The Locus of control affects a person’s behaviour which could be internal or external (McPherson, 2001). People with internal locus of control usually are self motivated and are capable of making independent decisions. However people with external locus of control are reliant on others to take decisions on their behalf. They are easily influenced by other people. Gottwald (2006), reports people with internal locus of control usually are motivated hence their behaviour change happens early. They are less likely to come out of the cycle when undergoing change of behaviour in the stages of change (Prochaska and DiClemente, 1982) model. The stages include PreContemplation (No intention to change)?Contemplation (Thinks about changing) ?Commitment (Determined to change behaviour) ? Action/ Maintenance (Person finds it difficult but changes behaviour)? Relapse (Person goes back to previous behaviour).This is considered healthcare professionals responsibility to help get them back in the cycle by working as a team with patients’ and their family. Gottwald (2006) reports a person may come out of the cycle few times before being able to complete the cycle. Nieuwenhuijsen et al 2006, report an understanding of a person’s environment (social environment or the work place environment), health models and personal factors are all essential to bring about health behaviour change. Five themes were being identified in relation to health promotion from the literature. The themes were: 1) Preventive aspect of health behaviour (Prevention against primary disease), 2) Early detection behaviour (includes early detection of a condition), 3) Self management of condition. Usually applies for chronic conditions, 4) Treatment adherence or being compliant to treatment, 5) Behaviour of health care providers. Nieuwenhuijsen et al 2006 and Beattie’s 1991, emphasised the need for client centred practice/ or client led practice and argues that a bottom up approach (Negotiation mode of intervention) is preferred to a top down approach (Authoritive mode of intervention), as the former is patient lead. The bottom up approach in health promotion is hence called “client led or client centred approach”.
Nieuwenhuijsen et al 2006, argues that the health promotion models however lacks adequate address of disability issues and also for its more uniform application needs to be based on comprehensive framework like the International Classification Of Functions (ICF).

Conclusion
The article has discussed the different types of health promotion used in rehabilitation. The aims of health promotion were then related to an area of practice. Health promotion and change of behaviour was discussed using the Stages of Change Model (Prochaska & DiClemente, 1982).It can be said that health promotion and rehabilitation have similar aims, as the emphasis of both is to give clients the control to decide for their own health. Healthcare professionals are the facilitators in the process and that the change of behaviour is only achieved better, if a client centred approach is used in interventions. The shift of emphasis is now recognised from professional directed to client led.

Reference:
- Almomani F, Brown C and Williams KB (2006): The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29 (4), 274- 281.
- Beattie A (1991): Knowledge and control in health promotion: A test case for social policy and social theory. In GabeJ. CalhanM, Bury M (eds)The sociology of the health service, Routledge: London.
- Black W and Living R (2004): Volunteerism as an occupation and its relationship to health and wellbeing. British Journal Of Occupational Therapy, 67 (12), 526- 532.
- Clark DB (1992): Dental Care for psychiatrist patients: Chronic Schizophrenia. Journal Of Canadian dental Association, 58 (1), 912- 916, 919-920.
- Davis SM (1995): An investigation into nurses’ understanding of health education and health promotion within a neuro -rehabilitation setting. Journal Of Advanced Nursing, 21, 951-959.
- Dinan et al (2006): Is the promotion of physical activity in vulnerable older people feasible and effective in general practice? British Journal Of General Practice, 56, 791-793.
- Ennis M, Thain J, Boggild M, Baker GA, Young CA (2006): A randomized controlled trial of a health promotion education programme for people with multiple sclerosis. Clinical Rehabilitation, 20, 783-792.
- Friedlander AH and Mahler ME (2001): Major depressive disorder : Psychopathology, medical management, and dental implications.American Dental Association, 132(5), 629- 638.
- Gottwald M (2006): Health Promotion Models. Rehabilitation: the use of theories and models in practice, First edition, Elsevier Churchill Livingstone. Chapter 7.
- Hajnal A (1997): Psychiatric and Psychological aspects of stomatologic diseases or stomatologic aspects of psychiatric diseases. Fogorv Sz, 90(6), 163- 176.
- Irwin R (1997): Sexual health promotion and nursing. Journal Of Advanced Nursing, 25, 170-177.
- McDonald S, Hetrick S, Green S (2004): Pre- operative education for hip or knee replacement. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CDoo3526. DOI: 10.1002/14651858.CD003526.pub2.
- McKinlay JB (1979): A case for refocusing upstream: the political economy of illness. In: EG Jaco, ed. Patients, Physicians and illness. New York: The free press.
- McPherson KM, Brander P, Taylor WJ, McNaughton HK (2001): Living with arthritis- what is important? Disability and Rehabilitation, 23 (16), 706-721.
- Medin J, Bendtsen P, Ekberg K (2004): Health Promotion and rehabilitation: a case study. Disability and Rehabilitation, 25 (16), 908- 915.
- Nieuwenhuijsen ER, Zemper E, Miner KR and Epstein M (2006): Health behaviour change models and theories: Contributions to rehabilitation. Disability and Rehabilitation, 28(5), 245- 256.
- Rosendahl E, Lindelof N, Littbrand H, Lindgren EY, Olsson LL, Haglin L, Gustafson Y, Nyberg L (2006): High intensity functional exercise program and protein enriched energy supplement for elderly persons dependent in activities of daily living : A randomised controlled trial. Austrailian Journal Of Physiotherapy, 52, 105- 113.
- Scriven A and Atwal A (2004): Occupational Therapists as primary health promoters: Opportunities and Barriers. British Journal Of Occupational Therapy, 67(10), 424-429.
- Sheiham A (1992): The role of dental team in promoting dental and general health through oral health. International Dentistry,42(4), 223-226.
- Watson N and Pulliam L (2000): Transgenerational health promotion. Holistic Nursing Practice, 14(4), 1-11.
- World Health Organisation (1986): Ottawa Charter for health promotion. First international conference on health promotion, Ottawa, 21 November 1986- WHO/HPR/HEP/95.1.