REHABILITATION MEDICINE by PROFESSOR ANTHONY WARD

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1 REHABILITATION MEDICINE by PROFESSOR ANTHONY WARD What is Rehabilitation Medicine? Rehabilitation Medicine (RM) is the medical specialty with rehabilitation as its primary strategy. It provides services for people with complex disabilities and aims to reduce the impact of disabling conditions. People frequently present with a diverse mixture of medical, physical, sensory, cognitive, communicative, psychological, social and environmental problems which require specialist input from a wide range of disciplines working together as a coordinated team. Accredited RM specialists therefore work in multidisciplinary teams across the range of healthcare, both in acute and community settings. RM in the UK serves two primary groups of people: those with neurological disabilities, including those with spinal cord injuries; and those with limb loss and other musculoskeletal impairments, which can, of course, affect all groups. The two main aspects of RM are rehabilitation and disability management. Rehabilitation is active, time-limited and aims to produce sustained reductions in the impact of disease and disability on daily life. Disability management is the use of focused rehabilitation interventions to prevent avoidable complications and minimise the effects of changing disability for people with long term conditions. Where Do RM Specialists Do? RM concentrates on people with complex needs. They usually require the assistance of at least two members of a multi-professional team to deliver a rehabilitation programme for them, whether they be an inpatient or outpatient. Inpatient activities tend to dominate in early

2 and post-acute programmes, as patients are not yet fit to go home after injury or illness, but also because it is easier to deliver such a programme in an institutional setting. An example of this is in the following case history: Following a collision between two motor cycles, a 28-year-old man receives a right above-knee amputation. RM assessment identifies impairments such as limb loss; pain; a previously unsuspected moderate brain injury; post-traumatic stress and limitations in activities such as walking, sleeping, concentrating; and restrictions in participation, including fulfilment of his family role. The outcome is enhanced by alterations in the environment, beginning with the provision of a prosthesis, specialist treatment for the brain injury and stress-related symptoms, and should eventually include adjustments made for the process of re-employment with access to vocational rehabilitation services. Continued attention to his social environment (including his family life and relationships with others in his social network), and to the bereavement aspects of his situation, are also crucial aspects of his rehabilitation. The role of the RM physician includes making the diagnosis and medical management of conditions causing complex disability as well as to address the medical complications that may occur. RM is the specialty of functioning and the essential responsibility is to address how the patient functions and from both a medical and a non-medical point of view. Disabilities can almost always be made more severe by omissions or ill-considered actions, and prevention is also a fundamental principle of RM. In many situations an RM specialist can make a vital contribution through anticipation and prevention of physical, psychological and social complications, based on knowledge of a condition s natural history and prognosis. RM specialists work with and support multidisciplinary teams in healthcare and social care settings to achieve these aims. The Scope of RM Practice Conditions Examples Sudden onset Brain or spinal cord injury, where a catastrophic onset is followed by a variable degree of recovery

3 Intermittent Relapsing remitting multiple sclerosis, where the condition itself may fluctuate, although the problem of unpredictability is ever-present. Progressive Impairments and disability gradually increase over a timescale, which may vary from a few months (in the case of rapidly progressive conditions) to many years (e.g. in secondary progressive multiple sclerosis or Parkinson s disease). Stable Cerebral palsy or post-polio, where the condition itself is often static, but the additional effects of degenerative and other changes may be superimposed over time, producing new disability and new rehabilitation needs. Some Facts and Figures In primary care, key areas of need for RM include: The prevalence per 100,000 long-term complications of trauma is 1200 for traumatic brain injury and 50 for spinal cord injury. Cognitive and behavioural disturbances are an important and neglected source of rehabilitation needs. Multiple sclerosis is the most common cause of progressive dementia in adults of working age. Neurobehavioural problems are the most important source of disability in survivors of traumatic brain injury. People with progressive neurological disorders, e.g. those with motor neurone disease or with late-stage multiple sclerosis make up smaller numbers, but generate highly complex needs, which absorb greatly disproportionate resources. In secondary care, the main needs for inpatient RM include: Trauma - the dominant category is brain injury. Estimates of the incidence of injuries leading to significant disabilities, have ranged from 75 to 175 per 100,000. Of these, perhaps 1% require admission to a neurological rehabilitation unit, but a larger number

4 require support in view of physical, cognitive and behavioural consequences. Spinal cord injury has an incidence of around 2 per 100,000. Acute medicine - stroke is the largest source of acute onset neurological disability. Some 15% of incident cases are of working age. Other acquired brain injuries, such as subarachnoid haemorrhage and hypoxia often present with complex needs due to cognitive as well as physical impairments. Individuals with long-term neurological conditions, especially progressive disorders, frequently require hospital admission due to either deterioration in their condition or intercurrent illnesses such as infections. In tertiary care, clinical neurosciences centres refer inpatients to neurological rehabilitation beds following acute management of conditions ranging from acquired brain injuries, including subarachnoid haemorrhage, to severe peripheral neurological problems, such as Guillain-Barré syndrome. How To Gain Access to Specialist Input The best way to find a RM specialist is through the general practitioner, but if there are difficulties there, the British Society of Rehabilitation Medicine (www.bsrm.co.uk) has information on the location of its members. Well over 95% of all RM specialists in the country belong to the Society. Most clinical neuroscience centres will also have well-established referral arrangements to consultants in RM and they are another source of referral. There are also eleven specialist centres for traumatic spinal cord injuries in the UK (nine in England and Wales, one in Scotland and one in Northern Ireland) and referrals are made in the same way as general RM units. They take their patients at the earliest possible time after injury to ensure the right kind of initial care and treatment. When someone is referred for an inpatient rehabilitation programme, he or she is usually assessed by one or more of the rehabilitation team and a decision is made as whether or not to accept the referral at that time. This is because some people are referred before they are full ready to benefit from rehabilitation and still are medically unstable. The recent Department of Health initiative on trauma care has now improved the pathway into rehabilitation for trauma survivors. Funding

5 Access to NHS specialist rehabilitation and RM is free to UK residents at the point of referral. Some people use their private health schemes to fund them, but this is usually unnecessary for inpatient activity. Some will use private means to support them once they are back at home and receiving outpatient treatment, such as therapy, equipment, etc. RM institutions have details of their charges and there are private rehabilitation hospitals in several UK cities. Searching the internet is an easy way to find their details.

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