Common musculoskeletal conditions

The Global Burden of Disease study identified musculoskeletal (MSK) conditions as the largest single cause of years lived with disability. MSK medicine and rehabilitation services worldwide are heterogeneous in nature in terms of patient pathway and involvement of various healthcare professionals. The service can be led by consultants in different medical specialties; in primary care by General Practitioners with a special interest in MSK disorders and in secondary care by rheumatologists, orthopaedic surgeons, neurosurgeons, pain specialists, rehabilitation and MSK physicians. Allied health professionals such as physiotherapists and extended scope practitioners now have a far greater role in managing MSK conditions in some countries such as the UK.

Disorders of the peripheral nerves

Accurate diagnosis is important for the rehabilitation of people with disorders of the peripheral nerves. There are a small but increasing number of disorders that are now specifically treatable. Even in those disorders of peripheral nerves that do not currently have a specific treatment, accurate diagnosis remains important in order to determine natural history and prognosis. This will help to determine the rehabilitation strategy. Some conditions may recover spontaneously—such as Guillain–Barré syndrome—while others are progressive—such as the hereditary motor and sensory neuropathies. Some may require surgical intervention (e.g. the brachial plexus injuries). Disorders of peripheral nerves usually consist of several symptoms, and this chapter covers a range of disorders to indicate the range and extent of these disorders.

Cerebral palsy

This chapter concerns rehabilitation for adults with cerebral palsy (CP). It begins with aspects of CP in childhood as the definition, aetiology, and classification of CP are all based on its origins preterm or in infancy. Adolescence is a time of great change for any person as they develop an autonomous existence and learn to take responsibility for various aspects of life. Having a disability such as CP brings additional challenges. Describing the dominant challenges of CP at different stages of life, including the transition to adulthood and during adult life, the chapter gives practical rehabilitation advice.

Multiple sclerosis

Multiple sclerosis (MS) is the commonest of the demyelinating CNS conditions and is the most frequent condition causing neurological disability in younger adults. It causes a combination of physical and cognitive disabilities, which, when combined with starting in young adult life and with an uncertain rate of progression, make it both challenging and responsive to rehabilitation. It is important to understand the criteria for diagnosis both to be able to discuss prognosis with patients and because symptoms may become apparent later which affect the diagnosis. It is more likely that rehabilitation medicine clinicians will see those with primary or secondary progressive MS than relapsing–remitting MS because the impact of disability tends to be greater and the current benefits from disease-modifying therapies less in progressive MS.

Mobility and gait

Mobility is a function of everyday life that allows us the freedom to move between places for work, social events, and activities of daily living. Reduction in mobility leads to activity limitations and participation restrictions, may increase dependence on others, and adversely affects the quality of life of the person, carers, and family. This chapter covers the anatomy and physiology of mobility and the gait cycle, then the effect of pathology on the gait. Assessing and examining mobility is covered in the context of planning rehabilitation programmes. Gait analysis, including three-dimensional computerized biomechanical assessment, is explained. Interventions and goals in gait rehabilitation are outlined, and avoidance and reduction of falls is also explained.

Respiratory issues in rehabilitation

Respiratory aspects of rehabilitation fall into two broad and overlapping categories. One is that of pulmonary rehabilitation which traditionally has focused on exercise, behaviour change, and educational-based intervention for those with chronic lung disease, predominantly chronic obstructive pulmonary disease, but its efficacy has since been proven in other chronic respiratory conditions (e.g. asthma, interstitial lung disease, cystic fibrosis, bronchiectasis, lung transplantation, and pulmonary hypertension). The other is rehabilitation in the context of neurogenic respiratory impairment, which is relevant to persons with both degenerative and monophasic-onset neurological conditions. These categories are overlapping as techniques from one may have relevance to the other. This chapter describes these aspects, investigations, and interventions.

Injections in rehabilitation medicine

Injection-based interventions are a useful addition to the rehabilitation physician’s practice. These can occur in either inpatient or outpatient settings and be for musculoskeletal (e.g. joint/soft tissue injections) or neurological conditions (such as antispasticity injections and nerve blocks). Local steroid injection is a well-proven and effective treatment for focal pain and inflammation, and this chapter covers commonly used steroid injections, as well as different agents and procedures with their indications (including botulinum toxin injection). It provides a guide to the use of appropriate general injection techniques and includes tables showing the dose and duration of action of commonly used steroids and local anaesthetics for injections.

History and examination

This chapter describes the principles of taking a history, an essential part of a comprehensive assessment of an individual by a rehabilitation physician, including presenting complaints; assessment of body function, activities, and participation; past medical and functional history; review of symptoms; personal and environmental history; and the individual’s perception of their condition. The approach taken in eliciting a history in rehabilitation settings is unique in that there is equal emphasis on understanding the impact of any illness on body function, activities, and participation in the context of that particular individual in the unique environment they live in. Describing examination of the neurological system and musculoskeletal system, the chapter provides details of how to design a rehabilitation plan, and methods for successful implementation.

Spinal problems

Low back and neck pain are extremely common symptoms in modern societies. The pain may result from abnormalities occurring within the trunk muscles, the vertebrae, the intervertebral discs, the facet joints, and the ligaments and from the spinal canal and the nerve roots themselves. Pain may also be referred from distant sites—such as the abdomen—and in some cases may be functional or psychogenic in nature. Pain can be described as acute or chronic; pain present for more than 3 months is considered as chronic. This chapter describes the assessment and management of different types of back pain.

Traumatic brain injury

Traumatic brain injury (TBI) is a subset of acquired brain injuries, a larger grouping that includes acute-onset diseases such as stroke as well as degenerative conditions such as the dementing illnesses. TBI is often considered separately to other acquired brain injuries due to differences in its presentation and how treatment is approached. TBI occurs over an extremely broad range of severities, from concussion through to profound and life-threatening damage. As the injury becomes more severe, the affected individual has an increasing risk of experiencing lifelong and complex physical, behavioural, emotional, cognitive and social problems. This chapter describes mechanisms, severity, consequences, related conditions, and stages of rehabilitation.