Following a major health problem, rehabilitation is the process by which an individual is helped to achieve his or her fullest physical potential. It is not tacked on to the recovery phase but begins with immediate preventative care in the first stage of an injury or illness. It is continued throughout the recovery or restorative phase, and involves adaptation of the patient to a new way of life. Its aim is to restore the patient to the maximum physical and mental capacity of which he or she is capable. The candidates for rehabilitation may have very different capacities for recovery, for example a baby with cerebral palsy and an elderly person who has had a stroke; but the principles governing the process remain essentially the same. Realizing a person’s fullest potential requires first of all a full analysis of the individual’s physical, mental and psychological attributes. Then the person is given guidelines and encouraged to channel his or her remaining resources into an intensive training programme, to achieve an independent and fulfilling lifestyle. The rehabilitation v team involved in this process may consist of medical and nursing staff, a physiotherapist, occupational therapist, speech therapist, social worker, and sometimes other people depending on the problem and available resources.

The rate of progress made in rehabilitation depends on many factors. Some are ‘internal’ – the patient’s self-awareness and self-esteem; any feelings of depression and guilt; his or her intelligence, personality and age; the degree of physical handicap; and the attitude to disability. Other factors are ‘external’ – the reactions of friends and family, and the financial and emotional environment.

Early rehabilitation

A major accident or illness is a tremendous physical and psychological shock, and the sooner rehabilitation begins the better. Patients are presented with short- and long-term goals as early as possible so that they can develop a sense of a worthwhile future existence, and progress towards it. The early (or acute) stage of rehabilitation may begin even before surgery or other treatment. The patient can be prepared physically and mentally for the postoperative experience by physiotherapy, breathing exercises, improved fitness and nutrition, and by meeting others who are coping with a similar disability such as amputation or colostomy. Also in the early stages the aim is to prevent initial complications which may retard later progress. Good nursing care is paramount in looking after the paralyzed or bed-bound patient, with particular attention to the skin. Pressure sores and infection can be prevented by frequent turning and massage. Immobilized joints rapidly develop painful contractures (tightening of the ligaments and capsules in the joints) which cause deformities and are very difficult to treat, so to prevent this physiotherapists and occupational therapists initiate an exercise programme.

Occupational therapy

The ordinary activities of daily living are those which allow us to be, and feel, independent. They fall into groups of tasks concerned with personal care, mobility, homecare and transportation. During rehabilitation these operations must be broken down into manageable exercises and painstakingly retaught to the patient in an individually tailored programme prepared by the team, particularly the occupational therapist (OT).

The OT teaches the patient sequences of movements as building blocks for activities, and how to adapt and exploit remaining capabilities. The OT can also provide splints to assist the patient’s muscles and joints, and furnish useful devices to help manipulate every-day objects. The OT also advises on the appropriate type and use of wheelchairs and more sophisticated remote-controlled devices which allow severely handicapped people some degree of control over their environment, hard objects. Do not try to move the casualty unless he is in danger, and never try to force anything into the mouth. Once the fit has stopped, place the casualty in the recovery position until fully conscious, reassuring him as you do so. Particularly if unconsciousness lasted for a long time, arrange for the casualty’s transfer to hospital.Many rehabilitation units have a model home where the patient can practise and gain confidence in new skills, and be realistically assessed before a trial period at home. Evaluation of the patient’s home facilities is undertaken by the OT and the social worker so that necessary alterations can be implemented before the patient returns, such as widening of doorways, a wheelchair ramp, an intercom, bathroom modifications and so on.

Amputation, mobility and manipulation

Amputation poses many rehabilitation problems. Those who require amputation of the lower limbs are frequently elderly, and have conditions such as diabetes, atherosclerosis or an infection. Rehabilitation may begin pre-operatively with exercises to strengthen the body and improve joint mobility, plus learning to balance on an artificial leg. Upper-limb amputees are often younger and fitter than lower-limb amputees but may face greater psychological, social and career problems. Rehabilitation of any amputee depends on many factors, including the level of amputation. With a high level of amputation more joints are lost and there is less muscle power and leverage to control a prosthesis, which becomes correspondingly heavier and more complex. Our legs are used mainly for walking. A leg prosthesis essentially helps the patient to balance, and possibly to walk. There is a variety of types available, with newer designs and lighter materials superseding older ones. Our upper limbs and hands, however, are used for much more precise manipulation and are more difficult to emulate mechanically. For suitable cases a myoelectric prosthesis, which responds to the patient’s own muscle signals in the stump through a compact power pack, is available. Advances in space and computer technology are continually being applied to create better models. Therapists usually try to fit a temporary prosthesis immediately after the operation, so that the patient’s psychological sense of loss is diminished and he or she accepts and uses the prosthesis more readily. It is especially important in the cas of upper-limb amputees to prevent the establishment of one-handedness.

Rehabilitation after heart problems

People who have had a heart attack or heart surgery tend to benefit enormously from rehabilitation. Early mobilization helps to avoid the many complications of bed-rest and speeds recovery. Under careful supervision and monitoring in the coronary care unit gentle

v low-intensity isotonic exercises are begun. Later, when the patient has left the unit, the exercises are progressively increased to activities such as rhythmic calisthenics (to improve muscle tone and mobility), walking and stair climbing. The patient may leave hospital as early as two weeks after the operation and attend a rehabilitation centre for about six weeks thereafter.

Psychology of rehabilitation

Serious illness is accompanied by psychological trauma. Mentally, the amputee also loses a part of his or her personality; the cardiac patient often becomes neurotic; hospitalization may lead to dependency and loss of self-esteem, depression and anxiety, which in turn diminishes a person’s chances of full recovery. In fact in one study of a group of heart-surgery patients, psychological rather than physical factors chiefly determined the degree of disability. One year after a heart attack only 31 per cent of those with emotional problems had returned to work, compared with 88 per cent of those with a more healthy outlook.