Rehabilitation doctor

We know that the real work starts when rehabilitation stops.

When you get home it will become apparent what consequences and invisible consequences you have been left with. These consequencen may often be present for a lifetime.

We let Karin Dankoor, rehabilitation physician, tell something about her profession.

 

Over the past fourteen years I worked as a rehabilitation physician in various workplaces.

As a result, I have treated various diagnostic groups, including patients with various forms of brain injury, which I will discuss later.

I currently work in a rehabilitation center where I am responsible for both inpatient and outpatient patients with mainly the diagnoses of CVA (stroke), Parkinson's, MS and other neurological diagnoses.

 

Rehabilitation medicine is a beautiful profession because our goal is: to let patients participate optimally again, despite the residual limitations after illness, accident or hospitalization.

The most important thing is that the patient functions as independently and autonomously as possible, that he/she can see what is still possible and that meaning takes shape again.
Residual symptoms can be of both physical and mental nature.

 

In the case of a (traffic) accident (without fatal outcome), the physical limitations will initially be noticeable and important. The patient and his/her environment are initially happy that the person in question is still alive and in a later phase they are happy that he/she is conscious again and out of danger. This recovery is visible.

 

Quite soon after, there is more attention for basic functions such as opening/closing eyes, reactions to stimuli and communication. This is an exciting phase, in which the difference between being able to make contact or not is essential.

 

In the case of a scenario in which these phases progress steadily and the body shows sufficient recovery, physical progress takes place and the patient responds to his environment.

 

Once these phases have been completed, attention is paid to the quality of these basic functions and also to the more complex functions such as memory and recognition. It starts to become noticeable if these are not of good quality.

When the complex functions such as speaking, hearing and seeing do not work, this is noticed fairly quickly. However, disorders in functions such as thinking, being oriented and behavior only become noticeable later, often much later.

These are the cognitive disorders and the behavioral disorders. Cognition contains a lot of functions, such as thinking and memory, but also being able to make connections, being able to plan and being oriented in time, place and person.

 

Disturbances in these complex functions confirm that there is brain damage, to what extent and roughly where this is located.
There are six ‘centers’ in the brain that each control a separate (complex) brain function, but there are many cross-connections between them. As a result, a disorder in one center can also affect the functioning of other centers.

 

This does not mean that the type of brain damage can always be located on a CT scan.
If the damage is visible on a scan, this helps with understanding, but it does not say everything. I have seen brain scans of patients who  surprised me that they were still alive. But I have also seen patients with serious problems, in whom little or no damage was demonstrable on the scan.

Be that as it may, it is a fact that cognitive disorders and/or behavioral disorders cause a patient to change, which has a major impact on both the patient and his or her environment.

The combination of cognitive disorders with usually also behavioral changes after brain damage is called 'symptoms consistent with non-Congenital Brain Injury'. This is usually not visible on the outside.

 

In the Netherlands, approximately 16,000 patients are discharged from hospital each year with the diagnosis of traumatic brain injury. We assume that many more people suffer from the same complaints, but not everyone ends up in the medical mill. The period from the onset of brain injury to a (reasonably) stable level of functioning with residual symptoms is long. Longer than the patient wants, longer than is emotionally bearable, longer than (some) relationships can handle, longer than one can ever imagine if one is not involved. It is also a period of much uncertainty, anger and frustration alternating with hope and experiences of success. There is a strong desire for ‘a normal life again’. I always compare it to a grieving process; the patient and their environment mourn the ‘loss of the old life'. A new balance must be drawn up in order to ultimately come to resignation and acceptance. People are looking for ‘a new life’.

 

The value of my profession is that we encounter and treat patients in all phases of recovery or reconstruction. From the Intensive Care Unit to home. In the first acute phase, we are mainly co-treaters and are asked for consultation.

When the acute phase is over, that is when patients are in the regular ward, and observations and tests show that there is (temporary?) residual damage, we become increasingly involved. There may be physical residual symptoms. There may also be changes in behavior, difficulty with impulse control and mood disorders. When the symptoms are clearly present, we are involved in the early phase and it can lead to a patient having to be admitted to a rehabilitation center.

 

However, when the symptoms appear to be less evident and not obstructive, the patient is quickly discharged home with hopefully a follow-up appointment with the rehabilitation physician. Unfortunately, this does not always happen.

This group of patients does go home with advice (rules of life), but there is usually no good guidance there. The problems become visible in the home situation. Fortunately, they often end up with the right supervisors via an alert GP, a good (physio)therapist or via via. Sometimes this is the rehabilitation physician, sometimes
outpatient supervisors (also called individual guidance).

 

Rehabilitation physicians often remain involved with patients for a long time, because rehabilitation only really starts at home. When the situation is complex, a patient will have to rehabilitate on an outpatient basis. Outpatient rehabilitation only ends when there is (the beginning of) acceptance and, if necessary, a good aftercare programme has been arranged. That often takes some searching.

 

Everything I wrote above was in the preface of the impressive book by FrankWillem Hogervorst.

He writes about the phases I mentioned in a compelling, accessible and humorous way. Without trivializing this entire process. It is told in a pleasant way while the underlying sadness is palpable.
I am sure that this book evokes a lot of recognition in all brain injury patients, and thus also gives recognition.

 

Karin Dankoor, rehabilitation physician