Why rehabilitation is important to recover from a stroke or injury

  • Wellness
  • Wednesday, 24 Jul 2019

A physiotherapist working with Phang.

Phang Kar Mun was only 20 when she sustained a brain injury from an all-terrain vehicle (ATV) accident.

She was in the United States, excited to begin the next chapter of her life as a university student in 2011. A few days before classes commenced, she went on an ATV jaunt with her friends. The vehicle flipped, throwing the young girl off, leaving her paralysed.

Phang’s world shattered.

After spending a year bedridden in hospital in the US, she returned home.

Fortunately, her loved ones knew the importance of a proper rehabilitation programme.

It’s been eight years since the tragic accident and thanks to rehabilitation, Phang is able to walk independently again albeit slowly.

Though she still has many issues to deal with, Phang is determinedly working on strengthening the muscles on the left side of her body and there is a glimmer of hope in her eyes as she speaks.

At 28, she has much to look forward to.

The goal of rehabilitation is to help patients with physical and/or cognitive disabilities regain as much functional ability as possible.

Though she still has many issues to deal with, Phang is determinedly working on strengthening the muscles on the left side of her body, which were affected by the accident.

“Rehabilitation is so important to get the patient back to some semblance of normal functioning – usually, it’s from post-accident, post-brain injury, post-spinal cord injury or post-stroke. We cannot promise that you will get back to where you were but we can try to get you back to where you were before as much as possible,” says rehabilitation medicine consultant Dr Saini Jeffery Freddy Abdullah.

The rehabilitation team is a multidisciplinary one comprising rehabilitation physicians, occupational therapists, speech therapists (if the patient has lost the ability to talk and express himself) and physiotherapists.

When someone suffers a stroke, the normal procedure is to consult a neurologist.

“He will stabilise you but that’s the extent of what he can do. He won’t be bothered to get you back to your normal functions – that’s our job as a team. I say team because I cannot do the job alone as I have to coordinate with the whole team to work towards specific goals for the patient.

“A person who has stroke will be bedbound so first, we work on getting him able to move a little, then he learns to sit in bed before being able to move about by himself. Most of the time, the physiotherapist will do this but for long term goals which are determined by the patient or caregiver, we need a team.

“Those goals may not just pertain to the patient alone, but also pertain to what the caregiver wants. For example, if his mother is bed-bound and he can’t move her or is getting a backache from lifting her, our role is also to train caregivers to do all these themselves,” explains Dr Saini, who specialises in stroke and neuro rehabilitation.

While many may give up hope or despair over their disability, rehabilitation can allow them to resume some daily activities.

He says, “If you were a concert pianist who had a stroke which affected your right hand, we try to get you to dress yourself, do domestic activities such as preparing a meal or driving and doing community things. But we cannot get you back to resuming your career unless the stroke was mild.”

A physiotherapist working with Phang.

Different role for each therapist

A physiotherapist looks into the patient’s physical aspects, e.g. if a patient cannot walk, then the physiotherapist trains him to walk whereas the occupational therapist looks after the functional aspects such as putting on clothes or using the toilet.

Occupational therapists also look into any difficulties the patient may have in his workplace, and find ways to modify the environment, e.g. if there are stairs in front of the toilet, they will teach a wheelchair-bound patient how to navigate the steps.

“For back pain, the physiotherapist will look at the pain, but most of the pain may stem from work. Either your posture or your sitting position is wrong, the computers are at a wrong level, or the desk/chair is too high.

“So, the occupational therapist will go to the workplace (if the employer allows it) and look into the ergonomics,” says Dr Saini.

He cites a case from Perkeso’s Return to Work programme. The organisation had referred a patient with an amputated leg who works in Pos Malaysia.

Dr Saini elaborates: “My role was to get him the correct prosthesis and work with the physiotherapist to strengthen his limbs so that he can use the prosthesis later, while the occupational therapist’s role was to make sure he could actually go to work.

“Unfortunately, the general post office was built at a time when it wasn’t necessary to make buildings disabled-friendly. The patient also had renal problems, was in a wheelchair and couldn’t walk long distances. He couldn’t access the building or get through the door. There was no carpark for the disabled either.

“My occupational therapist and I went to see what was best for the patient so the employer is now doing renovations, with help from Perkeso, who was willing to pay for part of the renovations.”

Ideally, rehabilitation should start from day one or two, depending on the patient’s condition.

“For patients who need amputation, they should start even before the amputation but most of the time, this doesn’t happen because other doctors don’t know the importance of rehabilitation.

“Also, there are not many of us around,” he says.

Dr Saini laments that not all patients are receptive towards rehabilitation because they don’t understand that it is a field where you have different people working towards a certain goal. The awareness is still very low.

This anti-gravity treadmill helps those with obesity and knee issues.

“To them, when you talk about rehab, it’s only physiotherapy. If you have stroke, the normal course of action is to seek out a physiotherapist, not realising that there are specific rehab programmes out there which are more goal-driven.

“The patient then keeps going for months and years but the physiotherapist doesn’t have any goals for you because there is nobody to guide the physiotherapist.

“At the end, when the physiotherapist cannot do anymore, he tells the patient he is rehabilitated to learn to adapt to things himself. With a rehab team, the goals are reviewed from time to time,” he says.

Lack of awareness

Sadly, awareness among the medical fraternity is also low.

He says, “If you seek treatment for stroke in a government hospital, most neurologists will refer you to rehab physicians because there are established rehab teams.

“But in the private setting, the neurologist will just refer you to the physiotherapist.

“A rehab physician’s role is to assess the patient and see what the patient is capable of doing functionally and the extent of what this patient can do. Then we work out a goal with the patient or caregiver; treat any complications that the patient has due to the disability such as pressure sores, difficulty in passing urine, infections, etc.

'If there is really nothing more that we can do and the patient is going to be dependent on the caregiver, we make sure he or she will not have too many complications,' says Dr Saini.

“So, there is the medical aspect and functional aspect. We try to prevent complications due to the disease that could lead to further disability.”

Another reason why patients may not opt for a complete rehabilitation programme is because insurance companies do not cover the total expenses as it involves more than one personnel carrying out their respective tasks.

“I wouldn’t say rehabilitation should go on forever but at least, the insurance companies should cover for a while until the patient can get to a better quality of life. Usually, they only cover up to 90 days and that’s it.

“Still, we try not to give up on patients. If there is really nothing more that we can do and the patient is going to be dependent on the caregiver, we make sure he or she will not have too many complications. At that stage, try to find means to make it easier for the caregiver,” says Dr Saini.

As for patients complaining that physiotherapy sessions are painful, Dr Saini jokes that there is no gain without pain!

He points out, “Yes, it is painful and though we try to make the session pain-free, it’s not possible unless it’s a simple injury or problem. There needs to be a little bit of suffering, otherwise the therapy doesn’t work.

“For example, if you have a frozen shoulder, we need to move you in a way that you can move that shoulder again – so there will be pain. Our treatment is to give you pain-relief afterwards. We try to alleviate your pain as much as possible so we probably will give you an ice-pack after the session for the inflammation or if necessary, some pain medication.”

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