Rehabilitation

Published on 09/04/2015 by admin

Filed under Neurology

Last modified 22/04/2025

Print this page

This article have been viewed 1078 times

Rehabilitation

Introduction

Neurological disease may result in chronic neurological deficit, and this accounts for a substantial burden of morbidity in the community. Some disabling diseases are particularly likely to affect young individuals, for example trauma, multiple sclerosis and cerebral palsy. The disability may be stable and long term or slowly progressive in these patients. Severe physical disability affects 420 000 people between the ages of 16 and 59 years in the UK, which is 0.75% of the total population.

Neurological rehabilitation is aimed at optimizing the level of function of the patient within his or her usual environment. This includes maximizing physical ability, preventing deterioration due to secondary disease, optimizing the patient’s environment, facilitating psychological adaptation to disability and encouraging social integration (Fig. 1). All these facets need to be assessed in providing the most appropriate support. Most of the burden of caring for the disabled falls on their families and the rehabilitation process involves training relatives and providing them with practical, emotional and psychological support.

Fig. 1 Reduction of handicaps by different interventions. These strategies are used concurrently rather than sequentially.

Impairment, disability and handicap

Neurological impairment, disability and handicap are key concepts in rehabilitation. Neurological impairment is a disturbance of the nervous system that results in an abnormality of function. It may occur at any level of the nervous system causing:

intellectual or emotional impairments

sensory or motor impairments.

Impairment causes disability if there is difficulty performing tasks that are normal for a human being. Disability causes handicap if the patient is unable to continue performing his or her normal role as a result of disability. For example, an attack of multiple sclerosis may cause leg weakness. This causes a disability if the patient can only walk short distances. If the patient is a postman, this causes a handicap, as he cannot perform his job, but if his occupation is sedentary, it may not result in the same level of handicap.

Recovery in the nervous system

Neurological recovery

Neurological regeneration may occur after damage, especially in the peripheral nerves. The type of disease is important in this regard; there is usually full recovery after classical demyelinating Guillain–Barré syndrome, but more frequently incomplete recovery after the rarer axonal variant. In the central nervous system, there is less scope for regeneration, but recovery may still occur. Two main factors contribute:

1. The initial pathological process may subside, e.g. reduction of inflammation in multiple sclerosis.

2. Plasticity effects. The central nervous system has less scope for recovery than the peripheral nervous system.

Predictors of neurological recovery

The nature of the disease and its treatment is the first important predictor. Demyelination is usually followed by more recovery than infarction, because axons are preserved. Severe brain trauma typically affects multiple sites and recovery may be slow. If there is a progressive disease, for example a tumour, then recovery will be determined by the success of treatment.

The extent of the damage is a key predictor. The greater the extent of the damage, the more incomplete the recovery, because there is less capacity for neuronal plasticity effects.

The age of the patient is also a predictor. Plasticity of the nervous system is greatest in children and declines rapidly with age. Damage to the language centres before the age of 6 years may result in transfer of language to the non-dominant hemisphere, but this is rare at older ages.

Recovery from disability and reduction of handicap

A patient may be able to perform a function even with a residual neurological impairment. For example, the disability of a patient with a foot drop may be treated with a foot splint. He or she may still be handicapped if unable to drive children to school, but this handicap can be treated with a hand-operated car. Alteration of the interaction between the patient and the environment allows the patient to perform tasks important in life, preventing handicap.

Aims of rehabilitation

The aims of rehabilitation are to encourage the facets of recovery described above:

To prevent complications.

To promote intrinsic recovery.

To teach adaptive strategies.

To facilitate function in the patient’s normal environment.

Prevention of complications

Neurological diseases cause deficits, which may predispose to numerous complications. These complications may in themselves be life-threatening or cause a deterioration of the underlying neurological condition. This impairs intrinsic recovery and impedes rehabilitation. Much of the acute management of the neurologically ill patient is in prevention and treatment of these complications (Table 1).

Table 1 Common medical complications of neurological deficit

Complication	Prevention
Pressure sores	Regular turning
Contractures	Passive movement of joints through the whole range
Thrombosis	Subcutaneous heparin, enhance mobility
Ventilatory failure	Ventilatory support
Pneumonia	Respiratory exercises, protect airway, especially with feeding

Promotion of intrinsic recovery

This is primarily the treatment of the underlying cause of the deterioration, for example intravenous steroids speeding recovery from a relapse of multiple sclerosis. Although an active area of research, no therapies have been proven to enhance recovery of the damaged nervous system.

Teaching adaptive strategies

This enables the patient to function despite any residual neurological impairment. Residual handicap can be addressed by assessing the patient’s needs in the usual environment and designing further strategies and aids to minimize handicap.

Facilitating function in a normal environment

The patient may be unable to achieve premorbid level of function. Family members may need to take additional roles and community-based services may be needed after discharge from hospital. The patient and carers will need help in psychological adaptation to their new roles.

Problem-orientated team approach

In contrast to the disease-orientated medical model, the rehabilitation approach is problem orientated. The approach is by a team, which addresses different facets of the patient’s problems. Rehabilitation is primarily undertaken by specialist therapists (Fig. 2). The role of the doctor is to integrate this activity, and treat certain physical problems that may be amenable to medical or surgical therapy (Table 2). There are four stages in this process:

1. Assess the patient and identify problem areas. Assessment requires a basic physical examination and interpretation of the patient’s impairments in the context of daily life, so obtaining a measure of disability and handicap. Disability can occur in various categories of activity (Box 1). The Barthel index provides a useful measure in spheres essential to every individual: ‘activities of daily living’.

2. Set goals to try and achieve improvements in function. These should be realistic as overambitious goals may not be achievable and may demoralize patients and staff. For a patient with a multiple sclerosis relapse, the initial goal may be to be able to stand.

3. Try to achieve these goals working with specialist therapists (see Fig. 2).

4. Reassess and set new goals once these goals are achieved. Once the multiple sclerosis patient can stand, the aim may be to take a few steps with help. If the goal is not achieved, an alternative strategy may be needed: for example, if a patient is unable to strengthen the hands enough to use ordinary cutlery, then modified cutlery may allow normal eating.

Fig. 2 Team approach to rehabilitation.

Table 2 Physical problems amenable to medical or surgical therapy

When the patient is nearing maximum recovery, he or she needs to visit the home and workplace with a physiotherapist and occupational therapist to assess specific needs in the usual environment.

Neurological rehabilitation

Neurological impairment, disability and handicap are key concepts in neurorehabilitation.

Rehabilitation involves assessing and optimizing function in all spheres of the patient’s usual environment.

Rehabilitation uses a problem-orientated, team approach to achieve realistic goals.

Rehabilitation involves the patient’s carers and community services.

Related

Neurology An Illustrated Colour Text