The science and art of rehabilitation

1. The science and art of rehabilitation Dr Prasanna Gautam FRCPE Aberdeen, UK

2. What is the difference?

3. What is rehabilitation? ‘’Restoration of a patient to his or her fullest physical, mental and social capability after an illness or accident’’

4. Prevalence of disability General Household survey from 1969 in the UK Grade 1-10; 10 being the most severe 14% had above 1 0.5% at 10 2% at 9 and 10.

5. Prevalence of disability In older population Prevalence rose after the age of 50 80% of all people above 85 had varying levels of disability. 20% of these had severe disability (> level 6)

6. Patient groups 1. With multiple disabilities e.g Head injuries, Multiple sclerosis, Stroke, Cerebral palsy, etc 2. With stabilised or progressive disabilities undergoing major personal or social transitions, e.g disabled school leavers, following separation or bereavement, acquiring new problems due to illness or age. 3. With complex clinical or technical solutions often requiring a team of experts in several relevant fields e.g amputees, special orthosis, neurogenic pain etc.

7. Forms of disability The five commonest form of disability Locomotor Hearing Personal care Mental Sensory

8. Components • Impairment: disturbance of normal structure or function • Disability: restriction or lack of ability to perform optimally • Handicap: The disadvantage due to disability The purpose of rehabilitation is to prevent or reduce the handicap from a disability which can no longer be reduced or eradicated

9. Objective assessment and monitoring • Disability implies subjective or qualitative entity. How does one measure this in an objective manner? Answer: There are several Measurement scales, e.g Barthel, 0-15; Katz, A-G, six activities Frenchay Activities Index, 0-3 in 3/12 MMSE, MSQ. HAD Hospital Anxiety and Depression scale of Zigmund and Snaith

10. When and for how long? • Begins at the first contact • May take years to complete.

11. The art of rehabilitation • Complex and daunting prospect for the therapist and any other clinician involved • Great expectations from the patients, family • Not equal importance given by the authorities • Not adequately understood by the doctors

12. Role of rehabilitation in prevention of disabilities • There are many conditions which can be prevented. E.g • Spasticity in Stroke patients • Uterine prolapse • Urinary incontinence • Muscle wasting • Bronchopneumoina • Malnutrition • Balance and posture, • Falls and fractures etc etc.

13. There is no agreed directive from the government or medical profession re Rehabilitation services in Nepal • RCP London 1983 Disability committee • Disablement Services Authority 1987; transferred Artificial limb and wheel chair Service to NHS, 1991 • Rehabilitation Medicine - as a specialty in 1989 • Mair Report in Scotland, 1972; 10 recommendations • Professor Cairn Atkins was appointed as the first consultant in Rehabilitation medicine at Princess Margaret Rose Hospital in Edinburgh. • Scott report ?1997. Reviewed the services and made further recommendations.

14. Is this sufficient? • This kind of service is available in Nepal currently

15. Physical Disability in 1986 and beyond RCP London (1) • There is urgent need to establish an effective medical disability service • Take into account the views of the disabled people and their families • Proposals must be cost effecient, using the local facilities • Management of disability is an integral part of total patient care and the responsibility of all clinicians

16. RCP recommendation continued (2) Some consultants should have designated responsibilities for specific conditions, e g incontinence, stoma care, pressure sores, head injury recovery service etc. System of internal and external checks and audit Timetable for developing adequate services in the districts and the regions. Administrative structure at district and region

17. Thank you for your attention