E-2 cross-condition problem management

Many problems in rehabilitation are associated with a wide range of conditions. The assessment and management of these problems are similar for patients, whatever the underlying situation and the content of treatments is the same. However, the therapy chosen may be influenced by the patient’s disease and other factors. Seven clinical issues are covered in this part of the syllabus, including the vital competency of managing chronic pain.

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Rehabilitation is not determined by disease diagnosis, although it is influenced by it. Some rehabilitation assessments or treatments are closely associated with specific types of disease, such as the association between cognitive difficulties and brain conditions. Other issues like pain or incontinence are seen across various diseases. The underlying illness may influence the management of these problems but is mainly independent. Thus, this section covers seven clinical issues which will need a similar approach, whatever the primary medical diagnosis. they are cross-condition problem management rehabilitation competencies.

Most of these problems are associated with diseases of the neurological system. Still, the syllabus has considered eight categories of conditions related to neuromuscular diseases, which is unsurprising because neurological conditions, including psychiatric and psychological disorders, are the commonest cause of moderate to severe dysfunction. Musculoskeletal disorders are probably the most typical cause of disability, especially relatively less severe disability. They are also strongly associated with chronic pain.

The cross-condition problem-management topics

Bowel and bladder dysfunction.

Damage to the nervous system, such as stroke, spinal cord injury, or peripheral nerve damage, constitutes a large group of conditions needing this rehabilitation competency. But they are not the only cause.

Patients with no neurological condition may struggle to manage their bowel or bladder function. Functional problems can affect excretory function, as they can affect all other activities. Loss of manual dexterity, such as in people with severe juvenile rheumatoid arthritis, causes a considerable challenge; limited mobility may cause incontinence secondary to urgency, lack of accessible public toilets or slowness exceeding the capacity to delay evacuation. Bladder disorders such as stress incontinence secondary to pelvic floor dysfunction are another common issue.

One important issue is often overlooked, “Incontinence is a highly stigmatising condition.”

Chronic pain.

I have already published several posts, including a review of a significant treatment trial, an appreciation of the NICE guideline, and a post emphasising the reality of chronic pain in response to an article on pain in a phantom limb.

Chronic pain is a significant public health problem: “In the UK the prevalence of chronic pain is uncertain, but appears common, affecting perhaps one‑third to one‑half of the population.” NICE (the National Institute for Health and Care Excellence) published guidance in 2021, Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.

Rehabilitation experts have a vital role helping peoplewith chronic pain and may soon be able to get a  credential in this skill.

Spasticity and its complications.

Rehabilitation is the only speciality with a significant interest in spasticity, and management of spasticity is an essential competency. Many interventions are used, so it will be no surprise that the evidence for many treatments is weak, with no good evidence to guide treatment selection. Spasticity is strongly associated with upper motor neuron lesions, and it is unclear whether the spasticity or reduced motor control is the leading cause of functional loss. There is little doubt that many patients find spasticity intrinsically unpleasant and require treatment to minimise discomfort and ease care. The primary outcome to be monitored should be the reduction in pain, discomfort, and deformity; improved function may arise, but it is an inappropriate measure of effectiveness.

Sexual dysfunction.

Two of Maslow’s five motivational needs directly concern sexual function, basic physiological and affiliation needs. Many factors affect sexual function, and sexual function is closely linked to social interaction and the opportunities to make a close relationship with another person and have the privacy to enjoy sexual activity. The risk in rehabilitation is that both the patient and the team focus on sexual function without discussing the more critical broader issues of interpersonal relationships, communication, and opportunities.


Satisfying hunger and thirst is the most basic of Maslow’s motivational needs; eating and drinking are pleasurable and essential to shared social activities. Thus, managing difficulties with eating and drinking successfully will considerably impact a person’s quality of life. Conversely, when this cannot be achieved, one must consider how the absence of food and drink’s pleasurable and social aspects will be replaced or accommodated.


Communication is one of the defining characteristics of humankind and is vital for establishing a close relationship and almost all social activities. It includes but is not restricted to speech and language. Technology such as smartphones is now central to most people’s communication. Understanding how and why communication is limited and being able to communicate with people whose ability is impaired are two vital skills.

Cognitive dysfunction.

Our cognitive ability is another defining characteristic of humankind, and alterations or losses affecting cognitive abilities usually affect all activities. Most disorders of the central nervous system affect cognition. Understanding normal cognitive abilities, how they can be limited, and how alteration may manifest in daily activities is crucial when assessing and managing anyone with a brain condition. In diseases of other systems, cognitive effects are less frequent, but previous or associated conditions may still affect cognition.

Conclusion - cross-condition problem management

These seven competencies consider functions that impact most aspects of a patient’s life, especially social participation. Most are associated with neurological disorders. Nonetheless, patients in all rehabilitation subspecialties may have problems in one or most of these domains and every rehabilitation expert should have these cross-condition competencies.

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