Goals and Prognosis From initial assessment of the patient it is important to know what you want to achieve with your patient and how. The use of clinical and technical outcome measures is a part of my expertise, but having functional end goals for the patient, helps them to stay more focused and carry through with the provided interventions. For example, it had been goals of mine to get a patient to use hand(s) to dress himself in two weeks, or to get a bed ridden patient walking with a walker in 10 weeks. Even though goals will vary from patient to patient, based on their pre-morbid history and personal needs, they must be specific, realistic and achieved within a certain time. Goals that are not met, due to arising complications or just failure of the patient to improve, have to be reassessed, and new goals must be set taking the patient as close as possible to the previous goals. With physical reassessment done, improvements and limitations should be pointed out to the patient. If theneurologicaldeficitsaresevereor theoutcome of rehab is uncertain, I rarely tell the patient that they can or cannot return to a lost activity. On the other hand, I will take small steps at a time with the patient towards achieving that activity or an activity that is similar but less laborious. A better prognosis of a patient is proportional to good attendance, intensive therapy (frequent longer-duration repetition-based sessions), good family support, sometimes a comprehensive health insurance plan or adequate financial support, and good self-esteem or willpower. Spontaneous healing of the damaged brain, spinal cord or nerves must be depended upon, even though it occurs at much slower rate than bone or muscle regeneration. In the case that this is non-existent or negligible, despite surgical or pharmacological intervention, a process of acceptance would have to be embraced, indicating a plateau in neuromuscular growth or regeneration. However, maintenance of current function and prevention of complications is paramount for this patient, via ongoing physiotherapy or home exercise program. Unconscious patients have a poorer prognosis, as recovery via physiotherapy relies heavily on their volition or awareness. However, I have witnessed physiotherapy helping them too, via stimulation and mobilization, to optimize ventilation and keep in-bed complications to a minimum, whether they are in intensive care unit on life support or they are at home. Neurological rehabilitation can be completed in 3-6 months for some, while 1-2 years for others. No matter the type of patient, the ultimate goals of physiotherapy are to make them as functional or independent as possible and to re-institute them into society, family life, work, school, sports or
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other leisure activities. The Psycho-Emotional Realm
Getting parents, guardians and teachers involved in rehab helps to reinforce positive behaviour, and steps should be taken to address any associated learning difficulties. The use of assistive devices and home modification are key for patients who have long term physical or sensory deficits. Rails, in-bath seats, raised toilet seats, commodes, urinals, walkers, canes, bed side steps and ramps are all instruments that can be installed or used to improve ease of mobility, transfers and self-care activities. Based on the limitations and needs of the patient, and the structure of their home environment, an assessment and recommendations can be made by the physiotherapist. I find education to be an old but promising tool of intervention. In my experience it has a four-fold effect: 1. Informing the patient about their condition, and what they need to do in managing it. Sensory disturbances including pain. Stroke patients may lose the ability to feel touch, pain, temperature, or position. 2. Educating caregivers, friends and family members about the limitations of the patient and what they need to do to support the patient’s well-being or recovery. 3. Sensitizing the public about such conditions/ limitations, so that they are more receptive and considerate to the affected population. 4. Upgrading my own pool of knowledge or skills through research or furthered education helps me to be adequately modern in my approach to neuro-physiotherapy. Educating other health care members about what I do through discussions or presentations gives them a more in-depth understanding of physiotherapy and encourages them to modify their management to facilitate rehab of the affected patients. A treatment program for a neuro patient has to be designed based on the individual. I may have gotten at least 5 stroke patients of the same age group, gender and section of brain being affected. However, I can guarantee you that they all will present with some difference, as everyone has different needs, goals and lifestyles. ‘Treat the patient and not only the condition’ I phrase. I also have not had exposure using state-of-the-art technology or equipment in neuro-physiotherapy, but I find that improvisation and creativity can compensate. Cueing, feedback and stimulation are key in neuro rehab whether tactile, verbal or visual, which expands their sensory awareness and bring about a more successful task or movement on the patient’s part.
With the unfortunate event of having a neurological condition, a patient may go through one of the five stages of grief (according to Elisabeth Kubler Ross and David Kessler): denial, anger, bargaining, depression and acceptance. A patient should be allowed to experience grief, but only to an extent, so that no major issues or events on their part arise in the later phase of rehab. My foundation psychology course at UWI Mona, might not have magically turned me in a ‘master of the mind’. However, a basic understanding of human thinking and how it affects behaviour have readied me in helping patients to have a better concept of their situation. Helping patients to internalize positive contextual factors, such as the presence of good family support or health care system and facilitating the exercise of their faith or spirituality have motivated these patients to perform well. I believe that the natural tendency of patients to worry or negatively think about their problems should be matched with optimism and effort. As a physiotherapist I have had to deal with my own thoughts and feelings towards managing my patients. In retrospect, neurological rehabilitation can be taxing and unrewarding. I have had cases of seeing children with brain cancer vomiting on themselves, to rehabilitating a young man with similar attributes as myself, only to see him regress into a coma. I have had to balance empathy with sympathy, patience with promptness, permissiveness with firmness, and optimism with reality. I have the concept that physiotherapists are more humans than super heroes, but we cannot afford to be depressed or negative around our patients. After all, they look forward for our expertise and motivation. All Stakeholders Aboard… I value my role as a physiotherapist, but the roles of others in rehabilitation have to be considered: neurologists, neurosurgeons, caregivers/nurses, general practitioners, psychologists/psychiatrists, occupational therapists, speech therapists, dietitians, teachers, employers, family members, and friends. A more holistic outcome will result from this with all members communicating among themselves and working together, making the rehab process quicker and more comfortable. The patient is the primary stakeholder as they are the ones affected the most, and their roles or responsibilities cannot be undervalued, whether it may be taking medication on time, attending treatment sessions regularly or complying to home exercise program. We will not be able to do everything for the patients or force them to get better, but we are here to help and guide them.
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