Rehabilitation medicineBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7169.2 (Published 14 November 1998) Cite this as: BMJ 1998;317:S2-7169
Modern medicine and assistive technology can greatly improve the quality of life for disabled individuals. Andrew Frank describes the scope of the specialty
- Andrew Frank
- Education Committee, British Society for Rehabilitation Medicine, The Royal College of Physicians, London NW1 4LE
Rehabilitation is the specialty which seeks to restore and maintain individuals at their maximum level of physical, mental, and social functioning. After the second world war services gradually reduced, a neglect that became appreciated during 1982, the international year of disabled people. A Royal College of Physicians report subsequently found services unevenly distributed and poorly coordinated across the United Kingdom, describing them as an “important if unplanned experiment … to set up an effective care service for physically disabled people without a substantial specialty of rehabilitation.”(1) It failed. Physicians interested in rehabilitation medicine created the Medical Disability Society, which became the British Society for Rehabilitation Medicine (BSRM). Since its inception in 1984, the society membership has grown from 180 founder members to 339 members today. Academic departments of rehabilitation medicine are slowly developing, usually with a special interest such as rheumatological or neurological rehabilitation. Now rehabilitation medicine is one of the fastest growing specialties in medicine.
Pros and cons of rehabilitation medicine
Exercises wide range of skills
Opportunities to work part time
Varied range of work includes community support for severely disabled adults, helping people back to work, neurorehabilitation, prosthetic rehabilitation, service development
Work with families over generations
Rapidly developing: unlimited scope for audit and research
Work with an extensive multiprofessional team
Work across both acute and community sectors
Helping people of all ages and both sexes
Influence without responsibility in relation to education and social services
Little acute or diagnostic work compared with most specialties
Limited private practice
Not “proper” medicine? - attitudes of medical colleagues
Role of doctor not always understood by lay colleagues
Multidisciplinary working can complicate decision making
Disabling diseases may be congenital or acquired.(2) Those that are acquired may have a fluctuating course (such as multiple sclerosis or rheumatoid arthritis), may steadily deteriorate (such as motor neurone disease or some cancers), or may go through a period of improvement (traumatic brain damage). At any moment, however, the patient is disabled, contributing to the pool of about six million physically disabled people in this country. Although many disabled people are elderly, children may have profound disabilities impacting on siblings, parents, and grandparents. While children and elderly people will usually be supported by specialist teams from paediatric or geriatric medicine, younger adults with physical disabilities have traditionally been neglected.(1) Providing services to support this group is one of our core functions.
The rehabilitation team
Rehabilitation doctors usually function as part of a complex multiprofessional team, which may embrace education, employment, engineering, housing, social services, and the voluntary sector as well as nurses, psychologists, and therapists. The size and format of this team varies with the range of rehabilitation provided. This greatly adds to the enjoyment and satisfaction of this specialty but occasionally creates its own difficulties. Rehabilitation doctors must be team players.
A consultant coordinates the components of support needed (both present and in the future) for individuals and for patient groups. Such support embraces medical, surgical, physical, environmental, and psychosocial facets of management.
Consultant posts may be based in either acute or community trusts, but consultants function across the acute and community services. By seeing individuals and families in their homes, consultants evaluate the physical, environmental, and psychosocial strengths and weaknesses of patients and their carer(s). Beds should be available in one trust to support both the assessment and treatment functions and to provide continuity of care if a disabled person has an intercurrent illness.
Such posts involve collaboration with community services. Where handover clinics are in place to plan for the disabled adolescentõs entry into the adult world, there is collaboration with paediatric services, schools, and colleges of education.
Rehabilitation consultants work closely with many groups of patients and their voluntary organisations - such as patients with traumatic brain injury (particularly after discharge from tertiary rehabilitation units), strokes, and musculoskeletal disability. Those with chronic neurological disability such as fluctuating or progressive multiple sclerosis are particularly challenging.
Technology is increasingly helping people with disabilities to become more independent. Any electrically operated device can be adapted for use by a disabled person, from door openers and telephones to video recorders and computers.
Disabled people value the ability to go out independently, and the governmentõs recent allocation of funds for electric powered chairs increases their independence. Carers (some who are themselves elderly or disabled) are now spared pushing their loved one uphill to the shops. Some profoundly disabled people (such as those with severe scoliosis and deformed hips) need made-to-measure seats prescribed by the rehabilitation team, sometimes from regional centres.
For those with a leaning towards technology, openings will develop as scientists link the technologies of mobility, communication, and environmental control. A recent report by the British Society for Rehabilitation Medicine has highlighted our potential to help disabled people in the future.(3) However, the body may heal before the mind does, and rehabilitationists have to be empathetic and understanding of emotional agendas before medical or technological interventions are likely to be fruitful.
Consultants in spinal cord injuries must be trained in rehabilitation medicine and have additional experience in managing spinal cord injury. The special problems associated with brain injuries (impaired cognition and communication) and spinal cord injuries (quadriplegia and impaired bladder function) require specialist physicians, therapists, and nurses in addition to appropriate surgical specialties (such as urology or neurosurgery) and social and psychological support.
These consultants have become highly specialised, particularly in the assessment and management of cognitive loss, spasticity, central pain, and sphincter disturbances. Implanted devices (and new treatments such as botulinum toxin) have the potential to markedly improve our management of many neurological symptoms, such as spasticity and chronic pain, and these changes will make regional appointments linked to departments of neurology or neurosurgery attractive.
Although elective surgical amputations for ischaemic limbs are becoming less common, trauma still accounts for both lower and upper limb amputations. Patients with peripheral vascular disease will also suffer (with or without symptoms) from cardiac and cerebrovascular disease, and often from diabetes, so physicians need a good working knowledge of these subjects. This is an area of rehabilitation where the psychological model of loss, grieving, and adjustment is easily understood, although patients have varying difficulties adjusting to newly acquired disability. Patients may get much help from fellow sufferers and local support groups as well as technology.
Although the most disabled individuals suffer from neurological diseases, most disabled people have musculoskeletal impairments due to inflammatory or degenerative disease of the spine or peripheral joints. These have traditionally been the province of rheumatologists or orthopaedic surgeons. It remains to be seen whether orthopaedic and rheumatological practice will maintain the expertise to support their patients with disabling illnesses or whether this will develop into a special interest of rehabilitationists. Low back pain is now clearly seen to require expert rehabilitation.
After the appropriate professional exams (such as MRCP or FRCS), the training programme will last four or five years, embracing neurological, spinal cord, musculoskeletal, and prosthetic rehabilitation. A core curriculum has been developed at local, regional, and national levels to encourage planned intellectual development for trainees with approved courses run by rehabilitation medicine and other specialties. The specialty is ideally suited to those needing flexible training. Further information about the wide variety of techniques used within the specialty can be found in standard texts,(5) or by contacting the BSRM.
Rehabilitation medicine has developed rapidly into one of the most exciting specialties within medicine. Crossing the divide between hospital and community, it provides challenges in facilitating the optimum quality of life for a neglected group of the population - younger adults with physical disabilities. Doctors provide support for individuals and their families and also collaborate with health and social purchasers to provide better services. Medical and technological advances are now making a large difference to this population, challenging the rehabilitationist of the future. There are plenty of choices for both the generalist and the specialist, and for research.