Central nervous system	Peripheral nervous system
Stroke – cerebral or spinal Multiple sclerosis Parkinson’s disease Traumatic brain injury Spinal cord injury Cerebral palsy Brain or spinal tumours Meningitis or encephalitis	Guillain–Barré syndrome Peripheral neuropathy Chronic inflammatory demyelinating polyneuropathy

Prevalence and incidence of neurological conditions

Neurological conditions are common. Around 10 million people in the UK live with a neurological condition which substantially affects their life [1]. Stroke is by far the commonest neurological condition. Each year, around 125 000 people in the UK, 700 000 in the USA and 1 million in the European Union have a stroke [2]. In the UK, of those individuals with neurological conditions, around 350 000 require help for most of their daily activities, and over 1 million require assistance with some daily tasks [1]. Each year 1% of the UK population are newly diagnosed with a neurological condition and 19% of hospital admissions are for a neurological problem requiring treatment from a neurologist or neurosurgeon [1].

Models of health care

Medical model

The medical model assumes that all illnesses are explained by disease and that the treatment of disease will restore the individual to health [3]. This model was originally developed in the late 19th and early 20th centuries following the scientific discoveries of infectious disease by Pasteur and cellular pathology by Virchow [4]. The medical model is based on reductionism and a dualistic notion of the mind and body. It evaluates individuals in isolation from their environment and takes no account of the social, psychological or behavioural aspects of illness or the patient’s experience of that illness [5, 6]. It was originally developed for the management of severe medical conditions. In these situations treatment of the disease may indeed result in substantial improvements in health. However, with the growing prevalence of chronic disease, the inadequacies of this model are highlighted. The model cannot explain symptoms for which there is no underlying pathology. It also fails to appreciate the complex interaction of social, psychological and environmental factors and their impact on the overall experience of illness by the individual.

Biopsychosocial model

The biopsychosocial model considers individuals as well as their health problem and the social context. It recognizes that health, disease, illness and disability result from complex interactions of biological, emotional, cognitive, social and environmental factors. It recognizes that psychological and social factors influence the person’s perceptions and actions, and therefore the experience of illness. This model suggests that effective treatment of the disease may not automatically result in the resolution of illness and disability. This model has been adopted by the World Health Organization as the basis for the International Classification of Function (ICF) [7].

Presentation of neurological conditions and ICF

Neurological conditions may result in a wide range of difficulties. These may include problems with physical ability, sensation, cognition, communication, behaviour and psychological functioning. The ICF developed by the World Health Organization [7] provides a useful framework to classify the consequences of disease (Figure 3.1) [8]. It is based on the biopsychosocial model of disability and supports the consideration of an individual’s situation within the context of biological factors and also the social and physical environment.

Figure 3.1 • Example of International Classification of Function applied to an individual with multiple sclerosis.

Management of neurological conditions

Neurological conditions may represent a one-off event followed by resolution and no further needs. However, neurological conditions often cause long-lasting difficulties which require management over the lifetime of the individual. These types of long-term neurological conditions broadly fall into one of four categories:

1. sudden-onset conditions

2. intermittent and unpredictable conditions

3. progressive conditions

4. stable neurological conditions, but with changing needs due to development or ageing [9].

People with neurological conditions often need to access a wide range of services such as those provided by health services, social services and charitable organizations. They will need information and education about their condition as well as support regarding finance and employment.

Key priorities for effective management include:

• prompt initial diagnosis and treatment

• emergency admission if required

• specialist rehabilitation

• effective symptom management

• prevention of secondary complications

• provision of relevant equipment

• adaptations to home environment

• support to remain in their own home

• vocational rehabilitation

• support for families and carers

• access to palliative care if required

• regular review and ability to re-access services in a timely manner [9].

General principles of rehabilitation

Rehabilitation has been defined as: ‘the use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration’ [10]. Rehabilitation is a continuous and coordinated process which starts at the onset of an illness or injury and aims to support individuals to achieve roles in society consistent with their aspirations [8]. Many individuals with neurological conditions will require access to rehabilitation services. Support needs to be provided for individuals throughout their life. Clear mechanisms for individuals to re-access relevant services are required (Figure 3.2). In addition palliative care is required to support individuals coming to the end of their lives [11].

Figure 3.2 • The ‘slinky’ model of the phases of rehabilitation.

(From RCP, BRSM. Rehabilitation following acquired brain injury: national clinical guidelines. London: Royal College of Physicians; British Society of Rehabilitation Medicine, 2003. with kind permission.)

Key aspects of effective rehabilitation

Person-centred service

The person should be at the centre of the service provided. Individuals should be provided with sufficient information about treatment options to allow them to be actively involved in all decisions regarding their management [9]. Information provided needs to take account of any communication difficulties that the individual may have. Attention should be paid to the person’s emotional needs as well as practical needs. Support should also be provided to family members and carers [9].

Specialist multidisciplinary team

Access to a coordinated specialist rehabilitation team is an important factor in effective management of the wide range of difficulties an individual may report [12, 13]. The specialist team members should include a doctor, nurse, physiotherapist, occupational therapist, speech and language therapist, clinical psychologist and social worker. Access to the expertise of other services is also important. Such services include dietetics, continence advisory service, orthotics, chiropody, pain management and spasticity management services, ophthalmology and liaison psychiatry.

Goal-setting

Goal-setting is an integral part of rehabilitation and allows the person and the specialist team to focus on key aspects identified as important by the individual [14]. Goals are specific time-bound measurable outcomes relating to a desired or expected future state. Goals are set by the individual, with support from the relevant team members. They guide and inform therapy, as well as providing a structure for the individual regarding future targeted outcomes [15]. Goals need to be challenging but achievable and include long-term (weeks/months) and short-term goals (days/weeks) [12].

Outcome measures

Outcome measures provide information regarding the outcome for an individual following rehabilitation. The use of validated standardized outcome measures is required within rehabilitation services to provide information on individual outcomes, as well as to allow service evaluation [16]. A wide range of outcomes measures have been validated, and they include those that reflect the perspective of the person as well as the clinician [17].

Evidence-based practice

Management programmes for people with neurological conditions need to be based on best available evidence. Evidence-based practice involves the integration of individual clinical expertise with the findings from the best available research [18]. A range of clinical guidelines have been developed to support improved care of people with conditions such as stroke or multiple sclerosis. Guidelines have been based on an extensive review of available research evidence combined with expert opinion [12, 13, 19, 20].

Chronic disease management

Chronic disease

Chronic diseases are diseases of long duration and usually slow progress. They are the leading cause of death and disability worldwide [21]. Many neurological conditions are chronic diseases requiring management over time. These diseases often have a range of persistent symptoms with no cure and the potential for significant impact on the individual’s quality of life [22]. Successful management requires an effective collaboration between the person and relevant health and social care professionals.