Listening to the Patient as a Route to Rehabilitation
Listening to the Patient as a Route to Rehabilitation
Several aspects of interest and consideration arise from this case report. The first consideration is that the well known quote 'doctor knows best' needs to be rethought because the role of the patient, with his or her unique needs and desires, must be included in any decision regarding his or her health. A further limitation in Italy is the imperativeness of parental consent to any medical treatment. Although, in theory, it is possible to challenge parents' decisions in the courts, this option is usually exploited only in the most severe and life-threatening situations. Prioritizing patients in therapeutic decisions has many positive consequences. First, it can lead to the choice of a potentially suboptimal therapeutic strategy (in our case, using an orthosis without orthopedic surgery or botulinum toxin injection) in the interests of improving the patient's well-being, sense of independence and compliance with the treatment. Second, rehabilitative goals should be decided in agreement with both the patient and their family, preventing treatment refusal. Third, dealing with patients who are growing, treatment may be tailored to their changing interests and desires: a child may be interested in playing, an adolescent may want to drive a motorbike to allow him to share experiences with other adolescents and as a step toward independence.
A second point of interest is the role of orthosis in the rehabilitation of adolescents. Flexa, the Lycra dynamic orthosis we chose, has a non negligible cost, but due to the relevant benefit reported even with the static variant of a similar orthosis, we hypothesized that it could prove useful as well. This kind of orthosis is often used in rehabilitative practice as an adjuvant to improve the efficacy of botulinum toxin injection and/or orthopedic surgery; to the best of our knowledge, however, no published studies have assessed its real efficacy. We believe that this case report shows that the orthosis is effective even if we had to use it on its own, given the lack of consent to other more invasive procedures.
Moreover, when compared in terms of mere costs with functional taping over a one-year period, the orthosis proves to be profitable (see Table 2). Additionally, in this analysis the 'total cost' we calculated does not include costs we could not quantify, such as the time spent by the parents to bring our patient to the Rehabilitation Center (considering a total of about one and a half hours lost per taping, this could lead to 150 hours per year), the increased feeling of dependence from both parents and therapist (a factor which is always dangerous in adolescence) and the poorer quality of life of both the patient and his family. These factors, however, notably increase the real cost of the taping treatment.
A third consideration lies in the importance of using tests, comparing pre-and post-treatment results, as tools for guiding rehabilitation. Our patient had a slight change in the Gross Motor Function Measure, but the improvement in the Melbourne Upper Limb Function was significant not only in terms of raw scores but also as an improvement of his functioning. Used in this way, tests provide a quantitative base for treatment evaluation without misleading the clinical judgment.
Discussion
Several aspects of interest and consideration arise from this case report. The first consideration is that the well known quote 'doctor knows best' needs to be rethought because the role of the patient, with his or her unique needs and desires, must be included in any decision regarding his or her health. A further limitation in Italy is the imperativeness of parental consent to any medical treatment. Although, in theory, it is possible to challenge parents' decisions in the courts, this option is usually exploited only in the most severe and life-threatening situations. Prioritizing patients in therapeutic decisions has many positive consequences. First, it can lead to the choice of a potentially suboptimal therapeutic strategy (in our case, using an orthosis without orthopedic surgery or botulinum toxin injection) in the interests of improving the patient's well-being, sense of independence and compliance with the treatment. Second, rehabilitative goals should be decided in agreement with both the patient and their family, preventing treatment refusal. Third, dealing with patients who are growing, treatment may be tailored to their changing interests and desires: a child may be interested in playing, an adolescent may want to drive a motorbike to allow him to share experiences with other adolescents and as a step toward independence.
A second point of interest is the role of orthosis in the rehabilitation of adolescents. Flexa, the Lycra dynamic orthosis we chose, has a non negligible cost, but due to the relevant benefit reported even with the static variant of a similar orthosis, we hypothesized that it could prove useful as well. This kind of orthosis is often used in rehabilitative practice as an adjuvant to improve the efficacy of botulinum toxin injection and/or orthopedic surgery; to the best of our knowledge, however, no published studies have assessed its real efficacy. We believe that this case report shows that the orthosis is effective even if we had to use it on its own, given the lack of consent to other more invasive procedures.
Moreover, when compared in terms of mere costs with functional taping over a one-year period, the orthosis proves to be profitable (see Table 2). Additionally, in this analysis the 'total cost' we calculated does not include costs we could not quantify, such as the time spent by the parents to bring our patient to the Rehabilitation Center (considering a total of about one and a half hours lost per taping, this could lead to 150 hours per year), the increased feeling of dependence from both parents and therapist (a factor which is always dangerous in adolescence) and the poorer quality of life of both the patient and his family. These factors, however, notably increase the real cost of the taping treatment.
A third consideration lies in the importance of using tests, comparing pre-and post-treatment results, as tools for guiding rehabilitation. Our patient had a slight change in the Gross Motor Function Measure, but the improvement in the Melbourne Upper Limb Function was significant not only in terms of raw scores but also as an improvement of his functioning. Used in this way, tests provide a quantitative base for treatment evaluation without misleading the clinical judgment.
Source...