Principles of neurological rehabilitation

his article reviews the basic principles that underlie the subspeciality of neurological rehabilitation.Neurological rehabilitation is in many ways different from the other branches of neurology.Rehabilitation is a process of education of the disabled person with the ultimate aim of assisting that individual to cope with family, friends, work, and leisure as independently as possible.It is a process that centrally involves the disabled person in making plans and setting goals that are important and relevant to their own particular circumstances.In other words it is a process that is not done to the disabled person but a process that is done by the disabled person themselves, but with the guidance, support, and help of a wide range of professionals.Rehabilitation has to go beyond the rather narrow confines of physical disease and needs to deal with the psychological consequences of disability as well as the social milieu in which the disabled person has to function.Thus, a key factor that differentiates rehabilitation from much of neurology is that it is not a process that can be carried out by neurologists alone, but necessarily requires an active partnership with a whole range of health and social service professionals.The key characteristics of the rehabilitation process are summarised in box 1. IMPAIRMENT, DISABILITY, AND HANDICAP cThese are key concepts that form the basic principles of neurological rehabilitation.The concepts were developed by the World Health Organization in 1980 (table 1).Although the terms have recently been modernised (and the new definitions are discussed below) the three original terms-impairment, disability, and handicap-are so well known and so ingrained in the philosophy of neurological rehabilitation that it is worthwhile discussing the older terms in the first instance.Impairment is just a descriptive term.It implies nothing about consequence.Examples are a right hemiparesis, left sided sensory loss, or an homonymous hemianopia.However, a right hemiparesis can obviously be relatively mild and lead to virtually no functional consequence, or can be severe and lead to a complete inability to walk.The functional consequence of impairment is the disability.Investigative and diagnostic neurology clearly needs to identify the impairment in order to lead to appropriate investigations and eventual diagnosis.However, neurological rehabilitation goes beyond the impairment and looks at the functional consequence and tries to minimise the impact of the disability on the individual.Thus, neurological rehabilitation mainly deals with disability.However, the concept of handicap is equally important.Handicap is the description of the social context of the disability.A person with a right hemiparesis, for example, may have a relatively mild weakness but even a limited weakness may have profound social consequences for some people.A young man with such a hemiparesis may, for example, wish to go into the armed forces or be a long distance lorry driver, and both occupations would be closed to him or an existing job may be lost.However, an older man with a similar degree of hemiparesis may have virtually no limitations placed on his lifestyle.Thus, handicap looks beyond the disability into the broader social context, which in turn will often have implications for the goals of the rehabilitation process.Neurological rehabilitation clearly needs to take into account not only the disability but also the particular handicap for the individual, while bearing in mind that some of the social and physical barriers depend on societal attitudes and the physical environment and may be outside the control of the rehabilitation team.Recently the WHO has produced a new classification, which has less negative connotations.Disability is now termed activity and handicap now termed participation.These definitions are outlined in table 2.The principles are the same, but the classification now places more emphasis on the individual's abilities rather than disabilities and more emphasis is given to social context.In other words it is a step towards the social model of disability and a step away from the medical model.