Regaining function
Rehabilitation physicians are trained to assess and help patients with disability recover as much bodily function as possible.
BY rights, around 30% of the population should come under their care at any one point in time; yet, their speciality is often misunderstood, not only by the public, but also by other doctors.
“This is where the problem is, because what society knows as rehabilitation can range from a simple massage to physiotherapy to a full-fledged multi-disciplinary team providing medical coverage around the clock,” says Universiti Malaya (UM) Faculty of Medicine Rehabilitation Medicine Department senior lecturer Associate Professor Dr Lydia Abdul Latif.
Even other doctors may not be completely clear or sceptical of the role and advantages of rehabilitation medicine, also known simply as rehab.
Says Assoc Prof Lydia: “For example, the cardiologists, sometimes they feel, what difference does it make whether you do cardiac rehab or not?
“But we told them, it is really not your decision, you just have to share the information on cardiac rehab. Give that knowledge to your patient and let your patient decide.”
She adds that some other doctors think that they can just work directly with the physiotherapist, rather than call in a rehabilitation physician.
But physiotherapy is often just one part of the rehabilitation process of a patient.
Says UM Petronas Chair of Sports Medicine and Rehabilitation Prof Datuk Dr Zaliha Omar: “I think the first concept you have get through is that rehab is not static, rehab is a process.
“So that patient going for physiotherapy is going for rehab, it’s part of the process, but it’s not all there is to rehab.”
The rehab process
The goal of rehab is to help patients with physical and/or cognitive disabilities regain as much functional ability as possible.
“We specialise in treating patients who develop disability following a disease process or injury.
“We are trained to look at the physical, psychological and functional aspects of the patient,” says Assoc Prof Lydia, adding that they then estimate the highest function the patient can regain and develop a programme to help the patient achieve it.
For example, she notes that heart attack patients are often unsure when they can get back to their daily activities, like working, driving, exercising, having sex, etc.
She says: “The first thing that we do is to stratify their risk to see whether they have high risk, low risk or moderate risk. This is actually a medical evaluation to assess their level of function.
“Then, we use the stratification to match what they would to need to return them back to their pre-morbid (before the heart attack) function in a safe manner, and to reassure them.”
Prof Zaliha adds: “In the practice of rehabilitation, our approach has to be holistic;
that means you look at the person in a holistic perspective in every sense of the word – biological, psychological, social and technological.
“And when you do that, you must be able to provide the patient with a comprehensive range of service.”
This service is provided by a multidisciplinary team led by the rehabilitation physician. It can include doctors from other specialities, nurses, clinical psychologists and allied health specialists like physiotherapists, occupational therapists and speech therapists.
Says Prof Zaliha: “Based on our assessment, we set goals, And once we have goals, we implement activities to get to them.
“All of us have the same goals that are agreed to by the patient and the family, but each of us have to do different things.
“For example, the doctor may have to give an injection, the physiotherapist may have to strengthen the walk, the occupational therapist may have to teach the patient how to put on and button their clothes, (and) psychologists look at their psychological profile and help them to stabilise their emotions and cope with their situation.”
Because there are so many processes to be done, someone has to lead and coordinate the efforts.
“When it comes to rehabilitation, the leader has to be a rehab physician,” says Prof Zaliha.
“Why? Because the rehab physician is trained to lead a rehab service, and rehab physicians are equipped with the knowledge, skills, and very often after a while, the experience, to enable them to network with all these people, to make sure they use all their skills (to help the patient), and get the patient to access all these services.”
She also says that it is not enough for the team to be multidisciplinary, it must also be interdisciplinary, i.e. communication between the team members must be done on a regular basis in order to properly monitor the progress of the patient.
Lack of awareness
Rehabilitation medicine initially developed during the First and Second World Wars due to the need of wounded soldiers for physical rehabilitation before returning to the battlefield.
Even now, Prof Zaliha says that 30% of the population rightfully require the care of rehabilitation physicians.
“Fifteen percent of the population are disabled, and another 15% are temporarily disabled because of illnesses and other medical conditions, so we’re looking at 30% of the population,” she says.
“The patients we manage are patients with any condition that will either potentially cause a disability, already have an overt disability, or have complicated disa- bilities arising out of birth, injury or illness.
“And it’s from intra-uterine to death, so we do womb to tomb,” she adds.
In Malaysia, Assoc Prof Lydia shares that patients who typically get referred for rehabilitation are those with neurological conditions like stroke, multiple sclerosis and cerebral palsy; spinal cord injuries due to trauma, infections or cancer; traumatic brain injuries; and diabetics with amputations.
However, she adds that the other conditions that rehab physicians should ideally play a role in treating, but which people do not usually associate with rehab, are chronic pain and cardiovascular disease, including heart attack and heart failure.
General awareness of rehabilitation medicine among the public is also lacking.
Prof Zaliha notes that while those living in cities like Kuala Lumpur, Georgetown and Johor Bahru, are probably generally aware of rehab, others are ignorant of it.
According to her, there are currently 72 certified rehab physicians around the country, with at least one or two in government service in every state, except Perlis (which shares with Kedah).
However, Assoc Prof Lydia says that it is important to note that rehab facilities are not well-distributed throughout the country.
“The state-of-the-art facilities where we provide state-of-the-art rehab services are largely confined to the Klang Valley, where we have two of the three speciality hospitals that provide full-fledged rehab medicine,” she says.
The three hospitals are UM Medical Centre in Petaling Jaya, Selangor, Hospital Rehabilitasi Cheras in Kuala Lumpur, and the Socso Rehabilitation Centre in Malacca.
UM is also the only university in the country offering a masters degree in rehabilitation medicine for doctors.
Due to this, Prof Zaliha says: “We have to work in teams with other people so that they can initiate the rehabilitation process, and we rehab physicians take on the difficult cases that are on the tip of the pyramid.”
The Health Ministry has also initiated a community-based rehabilitation programme, which utilises the expertise of rehabilitation physicians in training primary care physicians in the basics of rehab.
“In 1,000 health centres around the country, the primary care physicians actually provide very basic rehabilitation service, together with physiotherapists, nurses, and some have occupational therapists as well.
“That is very important, as the primary care physicians are our foundation,” says Prof Zaliha.