Rehabilitation assessment in general practice: why general practitioners should know about disabilit

The prevalence of disability in South Africa is 5%. (1) In thepublic sector the goal is to provide 90% of patient care at primaryhealth care level by 2010.2 Managed health care and resource limitationsdetermine where privately funded patients receive their care. Therefore,the general practitioner will frequently find him/herself having tomanage the needs of the disabled person within the community.Rehabilitation is achieved by modification of the impairment,
compensation for loss of function with assistive devices and techniques,
facilitation of social adjustment and acceptance, and modification of
the environment. (3,4)

This is usually achieved in the context of an interdisciplinary,
inpatient rehabilitation programme or a multidisciplinary, outpatient
rehabilitation programme. In both these settings the full professional
team, consisting of the rehabilitation medical practitioner and nurse,
speech therapist, occupational therapist, physiotherapist, social
worker, dietician and neuropsychologist, is on hand. Assessments are
completed by all team members and decision making is based on input from
all of them. Once maximal possible function has been achieved, 95% of
patients are discharged home on maintenance therapeutic programmes.

What happens to newly disabled persons after initial investigation,
management, and stabilisation? Admission to specialist in- or outpatient
rehabilitation programmes depends on clinician awareness of such
programmes, admission criteria, availability of programmes and financial
resources. Sadly, most deserving patients do not have access to such
programmes and are often discharged home without adequate or with
incomplete rehabilitation, in both the private and public sectors.

Training in disability and rehabilitation for undergraduate MB ChBstudents and postgraduate family medicine practitioners is virtuallynon-existent in South Africa. Internationally, despite rehabilitationtraining, general practitioners fail to detect 40% of disabilities. (5)Patients who have had rehabilitation as well as those who have not
had adequate or complete rehabilitation often end up at the general
practitioner with a particular problem. The aim of this article is to
provide a brief overview of the multiple and complex needs of the person
with disability.

Terminology

Impairment is when an illness or injury leaves a person with
abnormalities of body structure (e.g. amputation) or function (e.g.
hypothyroidism). Impairments are manifestations of pathology and can be
temporary or permanent, progressive, regressive or static, intermittent
or continuous, and slight or severe.

Activity limitation is when these impairments affect the ability to
perform daily activities, e.g. wash, dress, groom, walk, and produce
speech.

Participation restriction is when a person is unable to participate
in societal and life situations.

Function is an umbrella term used to describe normal body
functioning, and ability to participate in activities.

Disability, on the other hand, is the presence of impairments,
activity limitations, and participation restrictions.

Environmental factors comprise the physical, social, and
attitudinal environment in which people conduct their lives. These
factors can facilitate function or be barriers, causing disability.

Personal factors are features that are not part of the health
condition, e.g. gender, race, age, fitness, habits, coping styles,
social background, education, which affect functional outcome. (6)

All these components interact, influencing a person's
functioning and disability, as summarised in Fig. (1.)

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Therefore, the assessment of a disabled individual entails:

* a routine medical assessment

* an assessment of activities (and limitations) and participation
(and restrictions)

* an assessment of contextual factors (environmental and personal).

Role of the general practitioner

Every consultation, whether the patient is presenting with problems
related to the disability (functional issues, complications, chronic
medication, completion of insurance or medical reports, reassurance), or
unrelated problems, provides an opportunity to:

* initially confirm the diagnosis and prognosis into a taxi.* monitor maintenance of previously achieved levels of functioning

* assess abilities and reinforce positive life roles rather than a
sick role (7)

* identify current problems (medical and functional)

* identify current and potential complications (medical and
functional)

* treat appropriately at primary level

* make appropriate referrals (medical, therapeutic and community)

* co-ordinate all interventions

* organise follow-up

* advocate the needs of persons with disabilities (e.g. supply of
suitable continence devices and medications from medical aids and
community health centres).

Comprehensively identifying all problems and potential
complications

A systematic approach guided by a framework, such as the list given
in Table I, ensures comprehensive patient management. Complications
often develop insidiously and the list given below ensures that,
potentially, nothing is missed. Not all patients have all these
problems, but all problems related to disability are covered by the
list. The general practitioner doesn't have to treat all the
problems directly, but must be able to identify and refer appropriately.
Some problems may be managed simultaneously by two or more members of
the multidisciplinary team, including the patient and his/her family,
e.g. spasticity may require prescription of muscle relaxants, as well as
therapeutic exercises and positioning. (8) This generic approach allows
one to manage any disability and not only diagnoses with which one is
familiar. (9)

The assessment

The history will dictate the extent to which each system needs to
be examined. Standard medical evaluation techniques suffice but

must also include functional and contextual assessment. Observation
of the patient during the history taking and examination forms part of
the objective examination, which supports or refutes the complaints.
This is of special importance when assessing work potential. Examination
of individual systems is well documented in standard medical and
rehabilitation textbooks. (10,11) The following section is a brief
overview of key issues in each of these problem areas. (12,13)

Optimal medical management

Confirm the diagnosis. Further investigation and referral may be
necessary. An accurate diagnosis guides the prognosis and appropriate
management.

Medical problems may be acute (14) or chronic and generally fall
into the following categories:

* underlying cause and risk factors of the disability (e.g.
vascular, trauma)

* complications of deconditioning and immobility (pressure ulcers,
deep vein thrombosis, contractures, aspiration, respiratory infection,
constipation, reduced fitness, postural hypotension, osteoporosis)15

* secondary effects of the underlying insult (seizures, spasticity,
autonomic dysreflexia, neuropsychiatric disturbances, incontinence)

* secondary complications (urinary infection, renal reflux, bladder
stones, depression, pain).

All impairments across all systems must be optimally managed to
afford the patient the best possible outcome. Co-morbidities may limit
rehabilitation, e.g. limited cardiac reserve may limit effort tolerance
during amputee mobility training. The level of functioning immediately
before the most recent disabling event will limit rehabilitation
outcome.

With regard to prescription and recreational substances,
polypharmacy, drug interactions (e.g. warfarin) and effect of
medications on functional ability must be considered. Sedatives,
antidepressants, and alcohol may further impair borderline cognitive
functioning. A person with a hypertonic bladder can become incontinent with the addition of diuretics. Alcohol reduces the epileptogenic threshold.

Nutrition

Patients with hypertension, diabetes and dyslipidaemia have special
dietary requirements. Those with pressure sores have an increased need
for protein, calories, vitamins (C), and minerals (Zn). Immobile
patients become constipated, often aggravated by poor fibre and fluid
intake. Patients who tend to have urinary accidents may limit their
fluid intake. Sedentary patients have reduced energy needs, while those
with mobility impairments who mobilise actively with manual wheelchairs,
prostheses or walking aids have increased energy demands.

Skin and pressure care

Prolonged immobility of patients with or without sensory impairment
results in increased risk of pressure ulcers. Pressure mattresses and
wheelchair cushions alone cannot prevent pressure sores. The patient or
carer must take responsibility for pressure relief every 2-4 hours, day
and night. Precipitating and aggravating factors include wet skin
(incontinence), frictional forces (spasms and pulling the patient across
the sheet), anaemia and debility (diabetes, HIV), contractures
(prominence of bony points), crumbs and creased bedding, as well as
substance abuse. The patient must be strictly kept off the affected
area. Examine for pressure from orthoses, prostheses and assistive
devices, e.g. lateral maleolar pressure from the foot plate hanger of
the wheelchair.

Perceptual and sensory fall-out can result in unnoticed trauma.
Diabetics need regular monitoring of extremities, usually by a third
party, if their vision is poor.

Betadine as a wound dressing should be avoided in patients with
vascular compromise.

Scars should be mobilised to reduce cosmetic deformities and
restriction of movement. Aqueous cream can be used for this purpose.

Bladder and bowel management

Exclude pre-morbid causes of incontinence. Bladder and sphincter
function need to be assessed. Predictable, complete emptying without
intermittent leaks and avoidance of complications are the key aims in
persons with physiological incontinence, e.g. spinal cord injuries.
Patients with brain injury (stroke, head injury) may be functionally
incontinent owing to poor cognitive ability or perception of the need to
use the toilet, or poor mobility to access the toilet, commode or urinal bottle, or to manipulate clothing in time. A regular voiding schedule is
therefore indicated. Males who sit to urinate may find that they have
residual urine in their bulbous urethra after voiding. This results in
postmicturition dribble that can be managed by lifting the scrotum after
voiding in order to empty the urethra.

Facilitation of regular bowel emptying is critical from the first
day of injury to promote long-term social continence and to prevent
complications (megacolon, impaction, and diverticulitis). Chronic
constipation may lead to proximal liquefaction of stools, with the
patient presenting with diarrhoea.

Pain and discomfort

Spasticity and pain should be treated early and aggressively. The
longer these symptoms are present, the more difficult they are to treat.
Pain is a symptom--not a diagnosis --and a cause needs to be sought and
symptomatic treatment initiated. Spasticity may be aggravated by changes
in weather, infections, urinary stones, ingrown toenails, change in
psychological status and/or pressure sores.

Claudicating distance must be assessed in patients with vascular
conditions. Common causes of stump pain in amputees include infection,
neuroma and ischaemia.

Vision

Pre-morbid refractory and visual problems should be corrected.
Diabetics should be monitored for preventable causes of blindness
(cataracts and proliferative retinopathy). Brain-injured patients with
hemianopia and hemi-neglect should be approached from the hemiplegic side to provide maximal stimulation. Prism spectacles may improve
hemianopia, but only perceptual retraining and not spectacles will help
hemi-neglect. Visiomotor disorders can be treated with visual
therapy---exercises that focus on the eye muscles involved in eye
movements and accommodation. If diplopia causes headaches and dizziness,
eye patching can be alternated daily.

Sexual dysfunction

The physical and relationship aspects of sexual performance and
interaction need to be assessed. Patients may have a fear of
overexertion after having had a vascular event. Altered sensation may
affect the sexual experience. Impotence may be related to the lesion,
e.g. in spinal cord injury, or be a consequence of, for example,
digoxin, recreational drugs or vascular disease.

The ability to maintain menstrual hygiene and the need for family
planning must be assessed. Pregnancy may not be contraindicated, but
spasticity and deformity may affect childbirth, and functional ability
may affect child-rearing ability.

Behavioural and psychosocial adaptation, cognition and perception

The level of education can affect communication (history giving and
understanding). In work rehabilitation, the level of education
influences career options in the open labour market.

Some common behavioural problems that need to be understood in
persons with brain injury are:

* As the level of consciousness improves, the patient may become
restless and aggressive; sedation needs to be used judiciously to avoid
affecting cognitive functioning.

* Patients with cognitive deficit and loss of internal motivation
are viewed by family as lazy.

* A head injury victim's aggressive outbursts followed by
total non-recollection of events may be seen as manipulative behaviour.

Depression may be pre-morbid, reactive or organic after brain
injury and requires appropriate management and treatment. Patients with
severe cognitive impairments are often not suitable for active
short-term rehabilitation programmes especially if they cannot retain
learned information. However, families should be appropriately trained
how to apply therapeutic principles (e.g. positioning), prevent
complications (e.g. pressure sores) and provide a cognitive and
physically stimulating environment.

Community reintegration, work, school, leisure

Patients should become integrated members of the family and
community, fulfilling defined roles and participating in premorbid activities, e.g. shopping, socialising, religious activities. An
occupational therapist or clinical psychologist can assess for
mainstream or special school placement. Patients interested in sport can
be referred to Sport for the Disabled.

If the person is employed at the time of onset of disability,
employment should be maintained at all reasonable costs. Families often
insist on boarding for financial reasons. Alternatives (sick leave,
temporary disability, UIF, insurance, state disability) should be
considered. Termination of work should be carefully considered, taking
into account the prognosis, natural history to date and completion of
all therapeutic interventions. In difficult cases the help of an
occupational therapist should be sought. Structured activity in the
open, sheltered, or protected labour market, or in the domestic
environment, or a group that gathers weekly serves physical and
emotional therapeutic goals.

Activities of daily living

Gender, age, and social standing may influence an individual's
incentive to become independent, and thus the need for intervention.
Brain injury can affect intrinsic motivation. Placement in a care
facility usually negates the need for an active rehabilitation
programme. The majority of self-care tasks are performed for the
resident and ambulation is not encouraged unless safe and unless the
individual is independent.

Once discharged from a rehab programme, patients and carers are
responsible for their own maintenance therapy, comprising participation
in daily activities, stretching and positioning. Referral to a therapist
should be considered if functional deterioration is due to factors
beyond the patient's control, e.g. repeat stroke, change of
caregiver.

Assess which rehabilitation interventions have been received. If
there is poor acceptance, patients may 'shop' in the hope of
finding the 'magical cure' for their impairments. Observation
of communication and physical abilities during the evaluation adds
information to the assessment. A home visit will provide insight into
the environmental challenges some patients face. Typically, one thinks
of unpaved outdoor surfaces, outside toilets and lack of running water
and electricity that patients from disadvantaged communities face, but
split-level homes, narrow passages, and inaccessible baths and toilets
can be just as limiting. An occupational therapist will advise on
appropriate alterations, e.g. ramps, grab rails.

Assess the person's ability to eat (including cutting of food,
bringing food to the mouth, chewing and swallowing), wash the upper and
lower body adequately, get in and out of the bath, dress the upper and
lower body (including fastening of laces, underwear, zippers and buckles
and putting on orthoses and prostheses), toilet (getting to the toilet,
adjusting clothing timeously and safely, cleaning him/herself and
getting up from the toilet and readjusting clothing), groom (washing and
combing of hair, shaving, putting on make-up) and sleep. If possible,
the patient should choose what clothing should be worn. Safety can be
improved with a bath mat on the floor of the shower or bottom of the
bath. It is easier to get out of the bath by turning around onto the
knees than it is to try to push or pull up from a seated position.

Ask about chores such as sweeping, cleaning floors, washing,
hanging up clothes and ironing them, making beds, preparing food,
cooking, gardening, and general household tasks. These questions can
guide one as to the work potential of a person. If the person has a
dependant child in his/her care, address issues such as holding a young
baby, changing nappies, and bathing an infant.

If functional hand movement has not returned within 3 months after
brain injury, it is unlikely to happen. Patients with increased tone
must not squeeze a stress ball as this will aggravate flexor tone.

Mobility includes mobility in bed, playing sport, and transfers in
and out of a wheelchair to bed, toilet, chair, ground, and car.
Bedridden patients are encouraged to sit up out of bed for limited
periods, e.g. during mealtimes. Seating should be in the form of a
wheelchair or similar supportive chair. 'Lazy boys' are not
recommended as they negatively affect postural control. In
neurologically impaired patients, walking is only advised when it is
learnt in the correct neurodevelopmental sequence in order to promote
correct walking patterns. Enquire as to safety, distance, speed, need
for assistive devices, and ability to negotiate stairs (how many, with
or without a railing), curbs, obstacles and uneven terrain.

Power cannot be accurately tested in the presence of contractures
and spasticity. Painful loss of range of movement at large joints may
indicate heterotopic ossification.

What assistive devices or orthoses have already been prescribed?
Are these being used as prescribed and are they enhancing function as
initially intended? Correct wheelchair seating, on a suitable pressure
cushion, with the hips, knees and ankles at 90[degrees] with the pelvis
positioned so that the spine follows its normal curvatures, is important
(Fig. 3).

[FIGURE 3 OMITTED]

Transport

What transport is used to access health facilities and to fulfil
personal needs? Can the person transfer in and out of a vehicle and stow
assistive devices?

A patient requires competent physical and mental functioning to be
able to drive. Someone who has suffered brain injury may lack
sophisticated skills, e.g. concentration, insight, judgement, reasoning,
and ability to cope in an emergency. Do they have access to transport
for the disabled if locally available? Do they have a disabled parking
disc if they use private transport?

Communication (reading, writing, facial expression, hearing)

Dysarthria, dysphasia, comprehension, and cognition problems are
detected when the patient attempts to give the history him/herself.
Patients are encouraged to talk, rather than the accompanying carer
answering on their behalf. If the history needs to be taken from the
carer, the patient must still be the primary focus of the interview.
Establishing an accurate yes/no response, followed by naming of common
objects, are the first therapeutic steps in communicating with an
aphasic patient. A communication board is only effective for persons
with adequate cognitive ability. An ENT surgeon/audiologist's
opinion may be required to ascertain if a hearing device will be
beneficial.

Feeding, swallowing, dentition
With a facial palsy, dentures may no longer fit comfortably. They
need to be altered or remade. Some people prefer to be without their
dentures, but generally teeth will make an individual eat, look, and
speak better. Assess oral and dental hygiene. Oral thrush is often a
reason for patients to avoid eating. Patients who drool are encouraged
to 'suck' back the saliva rather than continuously dab the
side of the mouth as the will stimulate further drooling.

Does oral intake of solids and fluids match energy demands
(increased or decreased)? Can the person chew and swallow solids and
liquids? Is there choking, regurgitation through the nose or aspiration?
Has the person had repeated lower respiratory tract infections? Can they
maintain adequate nutrition? In patients with unilateral brain lesions,
choking is more likely to be due to poor positioning than to neurogenic causes. Once positioning is corrected, patients who continue to choke
should be evaluated by a speech therapist or ENT practitioner by means
of videofluoroscopy. A nasogastric tube does not eliminate aspiration of
upper GIT secretions. A PEG feeding tube is the preferred option for
long-term assisted feeding.

Finances

Interventions need to be planned within the limitations of the
patient's financial resources, be they private, medical aid,
compensation, or state funded.

Education and training of patient and carer

The doctor plays an important role in communicating the diagnosis,
prognosis and management plan to all parties involved--patient, family,
carer, health funder, and employer.

Conclusion

The above systematic approach will result in a problem list and
management plan which usually include several referrals and follow-ups.
An understanding of disability and its consequences empowers the general
practitioner to comprehensively manage all aspects of care of the
disabled individual within the community. The disabled person can then
achieve and maintain optimum health which, as defined by the WHO, is a
state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity. (16)

References

(1.) Statistics South Africa Census 2001: www. statssa.co.za
(accessed 12 May 2007).

(2.) Department of Health. Comprehensive Service Plan for the
Implementation of Healthcare 2010. Draft for Consultation. Cape Town:
Department of Health, Western Cape, 2005.

(3.) Office of the Deputy President. White Paper on an Integrated
National Disability Strategy. Pretoria: Rustica Press, 1997.

(4.) Office of the Premier Western Cape. Integrated Provincial
Disability Strategy. Cape Town: The Directorate Human Rights Progamme,
Office on the Status of Disabled Persons, 2002.

(5.) Davids R, Calkins MD, Rubinstein LV, et al. Failure of
physicians to recognise functional disability in ambulatory patients.
Ann Intern Med 1991; 114: 451 - 454.

(6.) World Health Organization. International Classification of
Functioning, Disability and Health (Short Version). Geneva: World Health
Organization, 2001.

(7.) Wade DT, Halligan PW. Editorial. Social roles and long-term
illness: is it time to rehabilitate convalescence? Clin Rehabil 2007;
21: 291 298.

(8.) Wade DT. Editorial. A framework for considering rehabilitation
interventions. Clin Rehabil 1998; 12: 363 - 368.

(9.) The European Board of Physical Medicine and Rehabilitation.
White paper on physical and rehabilitation medicine in Europe. J Rehabil
Med 2007; 39: 1 - 48.

(10.) Rolland P, McPhee MC. Clinical evaluation. In: de Lisa JA,
Gans BM, eds. Rehabilitation Medicine Principles and Practice.
Lippincott-Raven, 1998.

(11.) Michael W, O'Dell MW, Lin CD, et al. The physiatric
history and physical examination. In: Braddom RL, ed. Physical Medicine
and Rehabilitation. Edinburgh: Saunders Elsevier, 2007: 3-35.

(12.) Sammons H. The Evaluation of a Person With a Disability.
MBChB III Introduction to Rehabilitation. Cape Town: Stellenbosch
University, 2001.

(13.) Sammons H. Goal Orientated Management Plan. MBChB Mid Phase
Management of Persons With Disabilities. Cape Town: Stellenbosch
University, 2001.

(14.) Robinson KM, Siegler EL, Striem JE, et al. Medical
emergencies in rehabilitation medicine. In: de Lisa JA, Gans BM, eds.
Rehabilitation Medicine Principles and Practice. Philadelphia:
Lippincott-Raven, 1998.

(15.) Halar EM, Bell KR. Immobility in emergencies in
rehabilitation medicine. In: de Lisa JA, Gans BM, eds. Rehabilitation
Medicine Principles and Practice. Philadelphia: Lippincott-Raven, 1998.

(16.) Department of Health. National Rehabilitation Policy.
Pretoria: Department of Health, 2000.

In a nutshell

* The general practitioner often becomes the manager/co-ordinator
of chronic care for disabled individuals.

* The rehabilitation assessment comprises medical, functional and
contextual components, which are interdependent.

* All impairments across all systems must be evaluated.

* Rehab outcome is determined by pre-morbid level of functioning.

* The examination confirms the medical and functional status.

* A management plan reflects the multiple and complex needs of the
disabled individual.

* Management usually requires the input of more than one individual
from medical, therapeutic and community resources.

* Patients with pressure sores must not lie or sit on the affected
area.

* Patients' employment must be maintained at all reasonable
costs.

HELEN SAMMONS, MB ChB Principal Medical Officer and Acting Clinical
Manager, Western Cape Rehabilitation Centre, Lentegeur, Mitchells Plain,
Cape Town Part-time Lecturer, Centre for Rehabilitation Studies, Faculty
of Health Sciences, Stellenbosch University

Helen Sammons has been involved in clinical (public and private),
managerial, academic (under- and postgraduate training) and community
aspects of rehabilitation for the past 14 years. She developed the
present undergraduate MB ChB rehabilitation curriculum for Stellenbosch
University. With her present research on this curriculum, she hopes that
rehabilitation will eventually be incorporated into all undergraduate
medical curricula in South Africa.


Table I. Problems and complications
frequently encountered in
persons with disabilities

Medical-related aspects
Optimal medical management
Nutritional requirements
Skin and pressure care
Bladder and bowel
Pain and discomfort
Vision
Sexual dysfunction

Therapeutic-related aspects

Behaviour and psychosocial adaptation,
cognition and perception
Community re-integration, work, leisure
activities
Activities of daily living, mobility
Transport
Communication (reading, writing,
facial expression)
Feeding, swallowing, dentition

Other

Finances
Education and training of patient and
carer
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