What is neurorehabilitation?
The World Health Organisation defines rehabilitation as “a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments” (WHO, 2011).
Neurorehabilitation takes place after an acquired brain injury, spinal injury or neurological illness which has left the individual with complex issues. Some of the conditions needing neurorehabilitation are:
- Acquired brain injury, due to any cause including trauma, severe stroke, subarachnoid haemorrhage, meningitis, encephalitis, vasculitis, post-surgical, tumour, anoxia
- Spinal cord conditions, for example trauma with incomplete spinal cord injury, myelitis, myelopathy, tumour, combined brain/spinal cord injury
- Peripheral nervous system conditions such as Guillain Barre syndrome, neuropathy-post-critical-illness
- Multiple trauma
- Neurological and neuromuscular conditions such as multiple sclerosis, motor neurone disease, Huntington’s disease, muscular dystrophies, neoplasm, inherited metabolic disorders
- Severe musculoskeletal or multi-organ disease for example cases where rheumatoid arthritis has neurological complications
- Physical illness / injury complicated by psychiatric or behavioural manifestations or stable conditions (with / without degenerative change)
- Congenital conditions such as cerebral palsy or spina bifida in children or adults
- Post polio or other previous neurological injury
Neurorehabilitation consists of assessment, treatment and management delivered by a team of professionals with specific knowledge and experience in managing complex neurological conditions arising from a problem associated with the central nervous system, namely the brain or spinal cord.
The intensity and frequency needed by individuals requiring Neurorehabilitation treatment is ascertained by a group of medical and clinical professionals. In the event a new injury or neurological disease diagnosis then this is usually determined by the current treating team in an NHS hospital. Information is then collated into a Rehabilitation Prescription. (link to info about Rehab Prescriptions).
Neurorehabilitation can be provided through an inpatient stay in an NHS facility, an independently run facility which is what our membership consists of and also via outpatient services run by both the NHS and our membership as independent providers. The NHS often utilises the availability and expertise of independent provider companies as there is not sufficient provision within the NHS across both inpatient and outpatient/community Neurorehabilitation services.
The team is usually led by a Medical Consultant and where the main problems are primarily physical in nature, it will be a Consultant in Rehabilitation Medicine. Services treating those with predominantly neurobehavioural or neuropsychiatric problems will be led by a Consultant Neuropsychiatrist or Consultant Neuropsychologist depending on the complexity of problems and whether there are any pre or coexisting psychiatric conditions.
In addition to the Consultant, there may also be trainee specialty doctors in both Rehabilitation Medicine and other specialties dependent on the service being provided.
Neurorehabilitation is a treatment delivered by a team using an holistic approach to manage the physical, psychosocial and behavioural problems associated with both acute and chronic neurological illness. The Neurorehabilitation team works with service users in a collaborative manner, to achieve patient directed outcomes/goals. Services users are supported to achieve their maximum physical, psychological, cognitive and social potential to maximise their quality of life. Neurorehabilitation can take place when a person is still in hospital or when they are in the community or when they are in another type of residential, nursing or supportive care environment.
NHS Neurorehabilitation inpatient services are divided into levels, which reflect the level of complexity of the patient group they serve. Independent providers are not always allocated a specific level but will often be able to describe what they provide based on the following criteria.
Level 1 – high cost / low volume services for patients with highly complex rehabilitation needs that are beyond the scope of their local and district specialist services. These are normally provided in co-ordinated service networks planned over a regional population of 1-5 million through specialised commissioning arrangements.
These services are sub-divided into:
- Level 1a – for patients with high physical dependency
- Level 1b – mixed dependency
- Level 1c – mainly walking wounded patients with cognitive/behavioural disabilities.
Level 2 – Local (district) specialist rehabilitation services are typically planned over a district-level population of 350-500K, and are led or supported by a consultant trained and accredited in Rehabilitation medicine (RM), working both in hospital and the community setting. The specialist multidisciplinary rehabilitation team provides advice and support for local general rehabilitation teams.
Level 3 – local non-specialist rehabilitation teams provide general multi-professional rehabilitation and therapy support for a range of conditions within the context of acute services (including stroke units), intermediate care or community services.
The team usually includes some or all of the following professionals:
Depending on the type of neurorehabilitation provision, nurses from more than one discipline may be employed. E.g. Registered General Nurse (RGN), Registered Nurse Learning Disability (RNLD) or Registered Mental Health Nurse (RMN). Registered nurses work with trained support workers who provide day to day care and facilitate rehabilitation goals.
Due to the complexities of the central nervous system, people with neurological conditions can experience a variety of problems such as muscle stiffness or spasm (spasticity), muscle weakness, tremor, changes in sensation and difficulties with balance. The physiotherapist is able to assess and treat these impairments with the aim of restoring movement and function such as being able to sit or stand unsupported, walking and using the arms.
Occupational Therapists (OT)
The role of an OT is to maximise independence in all areas of life. This includes activities of daily living (ADLs) such as washing, dressing and eating, rest and sleep, education, work, play, leisure, and social participation. The OT assesses and treats physical, cognitive, visual and perceptual skills to enable the individual to engage safely in activities that are meaningful and realistic for them.
Speech and Language Therapists (SALT)
Speech and language therapists assess and treat problems with speech, language, swallowing and eating as a consequence of a neurological condition. This may also include provision of communication aids where speech and language is severely impaired. Speech and Language Therapists may also treat individuals who have had a tracheostomy tube inserted enabling them to wean from the tube and breathe independently.
Neuropsychologists are concerned with the relationship between the brain and behaviour. They assess and treat people who experience difficulties with memory, concentration, planning, language, reasoning, and other aspects of learning and understanding as a result of a neurological condition. They work closely with the team to establish routines and programmes that support changes in behaviour, including the implementation of compensatory strategies.
A clinical psychologist differs from a neuropsychologist, because they primarily focus on emotions and behaviours. For example, a clinical psychologist can help to look at reasons for emotional distress and offer support to either the individual themselves, their family, carers, or the rehabilitation team.
The two disciplines therefore complement each other with their difference in focus on behaviour and many services will include both within their neurorehabilitation team. Although it is also very common to see Clinical Psychologists with Neuro experience working within a Neurorehabilitation team as there is often a shortage of qualified Neuropsychologists within the UK – these individuals will usually receive their clinical supervision from Neuropsychologists.
Diet is an important part of rehabilitation and the dietitian will ensure that dietary needs are met to promote good health and recovery. In addition the dietitian works closely with the speech and language therapist where the patient has difficulty swallowing or eating which requires diet texture to be modified. This also includes provision of non oral feeding when swallowing is too impaired to allow normal eating and drinking.
Therapy assistants may be assigned to one particular discipline or may be generic in their role. The role of the assistant is varied but may include session preparation, assisting in sessions when more than one staff member is needed, running group sessions guided by the therapist, completing therapist defined treatment plans and various administrative tasks.
In addition to these core professions, other therapies/treatments (this is not intended to be an exhaustive list) may be considered and utilised if deemed appropriate, including:
Neurologic Music Therapy (NMT)
NMT is often included in neurorehabilitation programmes and is seen as a valuable adjunct to the more established rehabilitation therapies. NMT is based upon neuroscience research which suggests that music is a hard wired language and aims to improve thinking, sensation and physical difficulties through the use of music.
Art therapy can provide both physical and psychological benefits. Not only does it provide a means of expression, especially for those whose verbal language skills are impaired, but also an opportunity to improve social skills and physical abilities through manipulating art materials and working within a group setting.
Hydrotherapy is an additional treatment used by physiotherapists where exercises and treatment techniques are undertaken in warm water. This helps to relieve pain, relax and strengthen muscles, increase circulation, and subsequently improve function. Due to the supportive nature of water, hydrotherapy also allows those with limited movement to maximise their mobility.
Orthotic devices are applied externally to a joint or a limb in order to support and correct abnormalities and improve function. Devices include splints, inner soles or specialist shoes and can be ready made or bespoke. Some orthoses are provided by the occupational or physio therapist but for more specialised devices a referral is made to an orthotist.
As it is not always necessary for people requiring Neurorehabilitation to be an inpatient in a service there are many ways in which people can receive this specialist treatment whilst remaining at home and attending appointments either at home or by going into a hospital or other centre.
The same professionals listed for an inpatient setting will work with individuals to maximise a person’s quality of life and address any barriers to recovery. The team and/or individual clinicians involved in treatment are likely not be of a medical focus but those focussing on functional and cognitive recovery.