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OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Rehabilitation
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Oxford
Handbook of
Rehabilitation
Medicine
THIRD EDITION

Manoj Sivan
Associate Clinical Professor in Rehabilitation Medicine,
University of Leeds; Honorary Consultant Leeds Teaching
Hospitals and Community NHS Trusts; Honorary Senior
Lecturer, University of Manchester, UK

Margaret Phillips
Consultant in Rehabilitation Medicine, University Hospitals
of Derby and Burton Foundation NHS Trust, Derby, UK

Ian Baguley
Clinical Associate Professor, Macquarie University;
Clinical Senior Lecturer in Rehabilitation Medicine,
Westmead Clinical School, The University of Sydney,
Sydney, Australia

Melissa Nott
Senior Lecturer in Occupational Therapy, Charles Stuart
University, Albury-​Wodonga, Australia

1
1
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 v

Foreword

Many clinicians in practice today will remember their first Oxford Handbook.
The familiar cover and easily accessible layout was ground-​breaking in its
day, providing valuable clinical information in emergencies before the elec-
tronic resources that we take for granted today existed. Many of us learnt
our medicine from carrying it about in a white-​coat pocket where it could
be accessed soon after seeing a patient. My abiding memory of my own first
handbook is the exhortation in the early chapters ‘not to blame the sick for
being sick’. This is a very powerful concept that resonated with me deeply
and confirmed my choice of career in rehabilitation medicine where we can
do so much with medical interventions to alleviate the impact of disabling
conditions and where the cause of the disability cannot be cured. Over
the years, the Oxford Handbook stable has increased, encompassing many
clinical areas, and I was delighted when the first edition of the rehabilitation
medicine handbook was published.
Rehabilitation is an educational and problem-​solving clinical interven-
tion that aims to reduce the impact of disabling conditions on people’s
functioning. This is achieved through three main strategies—​restoration
of the function of impaired structures, reorganization of impaired path-
ways to deliver improved abilities, and reducing the discrepancy be-
tween the limited ability of disabled people and the demands of their
environment.
Manoj, Margaret, Ian, and Melissa in editing this handbook have
brought together a distinguished group of contributors who compre-
hensively cover the widest possible syllabus of topics in rehabilitation
medicine—​the medical management of disabling conditions. The topics
included in the handbook encompass a broader spectrum of conditions
than most of the rehabilitation medicine curricula across Europe and
North America, providing an invaluable insight into the rehabilitation of
these conditions.
Rehabilitation starts with a thorough understanding of the impact of the
condition on people and their families. The early chapters of the handbook
in Section 1 take us through the inclusive evaluation of the needs of the
person with a disability. Each topic-​specific chapter includes further infor-
mation on assessment in that clinical area. The chapters in Section 2 provide
valuable overviews of the management strategies of specific impairments
that cut across a range of disabling conditions. The condition-​specific chap-
ters provide a succinct, yet comprehensive, overview of the impact of each
diagnosis on the person and how to limit its impact.
 Foreword
vi

This edition has reviewed the state-​of-​the-​art in rehabilitation medicine

once more and provides an update to all clinicians interested in the field of
rehabilitation from medical students through to senior consultants—​we all
have something to learn from the knowledge in this useful volume.

Professor Rory J. O’Connor

Charterhouse Professor and
Head of the Academic Department of Rehabilitation Medicine,
University of Leeds, and Lead Clinician in Rehabilitation,
the National Demonstration Centre in Rehabilitation,
Leeds Teaching Hospitals NHS Trust, Leeds, UK
 vii

Preface

The Oxford Handbook of Rehabilitation Medicine is designed to provide con-

cise information on rehabilitation aspects of care for adults with long-​term
medical conditions. The second edition was published in 2009, and since
then, there have been advances in the management of medical conditions
and new rehabilitation approaches and technologies have emerged. New
guidelines and treatment protocols have been agreed based on emerging
evidence and consensus. An updated edition of the handbook was there-
fore much needed to cover all these aspects.
Rehabilitation medicine is an expanding medical specialty, and worldwide,
there is a wide scope of practice in the specialty, particularly in the fields of
pain, musculoskeletal medicine, trauma, cancer, cardiopulmonary rehabili-
tation, and rehabilitation technology. We have made a sincere effort to in-
clude all the relevant areas by adding 14 new chapters in this new edition.
Colour pictures, diagrams, and management flowcharts/​algorithms have
been introduced to make the information easily accessible. The handbook
luckily manages to retain its pocket size in spite of our enthusiasm to cover
everything new and novel in rehabilitation.
The book has two sections: Section 1 on common clinical approaches and
Section 2 on condition-​specific approaches. The clinical approach section
outlines the management of common symptoms encountered in rehabilita-
tion settings. The subsequent section on specific conditions provides infor-
mation that will enable the reader to put the symptoms in context with the
condition and provide direct management in a comprehensive and holistic
manner. Every chapter has list of further reading resources that includes
journal articles, textbooks, and online material.
This handbook, although aimed at medical doctors, will prove useful to
other members of the multidisciplinary rehabilitation team such as physio-
therapists, occupational therapists, nurses, psychologists, speech and lan-
guage therapists, dieticians, support workers, and other allied healthcare
professionals. The handbook will also appeal to doctors in the related spe-
cialties such as neurology, orthopaedics and trauma, palliative medicine,
geriatrics, and pain medicine.
The new editorial team have enjoyed bringing together British and
Australian perspectives on various aspects of rehabilitation and it is hard
to believe we never had any disagreement during the years of preparing
this new edition. The four of us have worked extremely hard in ensuring
that every chapter is reviewed meticulously by each of us and meets the
standards we had set for this handbook. We hope our readers find the new
edition up to date and useful in their everyday practice of improving the
lives of individuals with long-​term conditions.
 ix

Acknowledgements

We would like to dedicate this work to our patients and their families who
keep us motivated and inspired by their resilience and determination to im-
prove their abilities even when the odds are all stacked against them. The
material presented in this handbook has been written by experts in their
areas and we would like to express our gratitude to all the contributing
authors for their time and efforts. We are grateful to our reviewers who
provided valuable insights and suggestions to improve the quality and scope
of the chapters. This work would not have been possible without the sup-
port and encouragement from our families and friends who did not mind us
working over the years in the small hours after busy clinical commitments.
We would like to particularly thank the Oxford University Press team for
their help, guidance, and patience throughout the process as this edition has
been an ambitious revamp of the previous edition and needed energies and
efforts of essentially writing a new book.
 xi

Contents

Symbols and abbreviations xiii

Contributors xv

Section 1 Common clinical approaches

1 Concepts of rehabilitation   3
2 Epidemiology 21
3 Rehabilitation team 37
4 Organization of services 47
5 History and examination 63
6 Rehabilitation assessment and evaluation 77
7 Cognition and behaviour 89
8 Communication 105
9 Swallowing 113
10 Spasticity and contractures 123
11 Chronic pain 141
12 Neurogenic bladder and bowel 167
13 Sexual function 181
14 Skin problems 195
15 Injections in rehabilitation medicine 203
16 Cardiac rehabilitation 213
17 Respiratory issues in rehabilitation 233
18 Mobility and gait 251
19 Family and relationships 269
20 Vocational rehabilitation 279
21 Orthotics 289
22 Wheelchairs and seating 305
 contents
xii

23 Technical aids and assistive technology 319

24 Personal factors in rehabilitation 339
25 Rehabilitation in critical illness 347

Section 2 Condition-​specific approaches

26 Traumatic brain injury 367
27 Spinal cord injury 385
28 Stroke 401
29 Multiple sclerosis 417
30 Cerebral palsy 437
31 Neurodegenerative conditions 451
32 Prolonged disorders of consciousness 471
33 Disorders of the peripheral nerves 483
34 Muscle disorders 503
35 Common musculoskeletal conditions 519
36 Musculoskeletal problems of
upper and lower limbs 539
37 Spinal problems 557
38 Cancer rehabilitation 571
39 Geriatric rehabilitation 585
40 Burns rehabilitation 601
41 Amputee rehabilitation 615

Index 643
 xiii

Symbols and abbreviations

E cross reference CSF cerebrospinal fluid

M website CT computed tomography
ABI acquired brain injury DAI diffuse axonal injury
ACE angiotensin-c​ onverting enzyme DALY disability-​adjusted life year
ACS acute coronary syndrome DFLE disability-​free life expectancy
ADLS activities of daily living DM1 myotonic dystrophy type 1
ADRT advance decision to refuse DM2 myotonic dystrophy type 2
treatment DMARD disease-​modifying
AED antiepileptic drug antirheumatic drug
AFO ankle–​foot orthosis DMT disease-​modifying treatment
ARDS acute respiratory distress DOLS Deprivation of Liberty
syndrome Safeguards
ASIA American Spinal Injury DVT deep venous thrombosis
Association DXA dual energy X-​ray
AT assistive technology absorptiometry
ATA Assistive Technology ECG electrocardiogram
Assessment EEG electroencephalography
BMI body mass index EMG electromyography/​
BONT botulinum toxin electromyogram
CABG coronary artery bypass ES electrical stimulation
surgery ESD early supported discharge
CBR community-​based ESR erythrocyte
rehabilitation sedimentation rate
CBT cognitive behaviour therapy FSH facioscapulohumeral muscular
CFS chronic fatigue syndrome dystrophy
CGA Comprehensive Geriatric GABA gamma-​aminobutyric acid
Assessment GBS Guillain–​Barré syndrome
CGRP calcitonin gene-​related GCS Glasgow Coma Scale
peptide
GI gastrointestinal
CHD coronary heart disease
GMFCS Gross Motor Function
CHF chronic heart failure Classification System
CK creatine kinase GP general practitioner
CNS central nervous system GS grip strength
COPD chronic obstructive pulmonary HD Huntington’s disease
disease
HKAFO hip–​knee–​ankle–​foot orthosis
CP cerebral palsy
HLA human leucocyte antigen
CRP C-​reactive protein
IADLS instrumental activities of
CRPS complex regional pain daily living
syndrome
 Symbols and abbreviations
xiv

ICF International Classification PCS post-​concussive syndrome

of Functioning, Disability PD Parkinson’s disease
and Health
PDOC prolonged disorder of
ICU intensive care unit consciousness
INR international normalized ratio PE pulmonary embolus
ITB intrathecal baclofen PEG percutaneous gastrostomy
IV intravenous PSH paroxysmal sympathetic
KAFO knee–​ankle–​foot orthosis hyperactivity
KO knee orthosis PTA post-​traumatic amnesia
LIS locked-​in syndrome PTSD post-​traumatic stress
disorder
LL lower limb
QALY quality-​adjusted life year
LMN lower motor neuron
QOL quality of life
LOS length of stay
RA rheumatoid arthritis
LRTI lower respiratory tract
infection REM rapid eye movement
MCP metacarpophalangeal ROM range of motion
MCS minimally conscious state SCI spinal cord injury
MDT multidisciplinary team SCPE Surveillance of Cerebral Palsy
in Europe
MFS Miller Fisher syndrome
SMART Sensory Modality and
MI myocardial infarction
Assessment Rehabilitation
MMSE Mini-​Mental State Examination Technique
MND motor neuron disease SSRI selective serotonin reuptake
MODS multiple organ dysfunction inhibitor
syndrome TBI traumatic brain injury
MRC Medical Research Council TENS transcutaneous electrical
MS multiple sclerosis nerve stimulation

MSK musculoskeletal TIA transient ischaemic attack

NDGC neurodegenerative condition TN trigeminal neuralgia

NG nasogastric TUG Timed Up and Go

NHS National Health Service UL upper limb

NICE National Institute for Health UMN upper motor neuron

and Care Excellence UTI urinary tract infection
NIV non-​invasive ventilation VO2 MAX maximal oxygen uptake
NSAID non-​steroidal VR vocational rehabilitation
anti-​inflammatory drug
VS vegetative state
OA osteoarthritis
WHO World Health Organization
PA physical activity
WS walking speed
PCI percutaneous coronary
intervention

Contributors
Dr Stephen Ashford
NIHR Clinical Lecturer and
Consultant Physiotherapist
and Regional Hyper-​acute
Rehabilitation Unit, Northwick
Park Hospital, Harrow, UK
10: Spasticity and contractures
Dr Hannah Barden
Adjunct Researcher, Charles
Stuart University, Albury-​
Wodonga; Occupational
Therapist, Westmead Hospital,
Westmead, New South Wales,
Australia
10: Spasticity and contractures;
40: Burns rehabilitation
Dr Angela Clough
Clinical Lead, Musculoskeletal
Physiotherapist, Hull & East
Yorkshire NHS Trust, and Co-​
Chair, Yorkshire & Humber
Regional Network of Chartered
Society of Physiotherapists, UK
35: Musculoskeletal problems of
upper limb; 36: Musculoskeletal
problems of lower limb
Dr Catherine D’Souza
Palliative Care Lead, South
Canterbury District Health
Board, New Zealand
31: Neurodegenerative conditions
Dr Hanain Dalal
Honorary Clinical Associate
Professor, University of Exeter
Medical School, Truro Campus,
and Knowledge Spa, Royal
Cornwall Hospital, Truro, UK
16: Cardiac Rehabilitation
xv
Dr Laura Edwards
Clinical Associate Professor
in Rehabilitation Medicine,
University of Nottingham and
Honorary Consultant, University
Hospitals of Derby and
Burton Foundation NHS Trust,
Derby, UK
31: Neurodegenerative conditions
Dr Helen Evans
Highly Specialist Physiotherapist,
Gait and FES Service, University
Hospitals of Derby and
Burton Foundation NHS Trust,
Derby, UK
18: Mobility and Gait
Mr Jonathan Flynn
Programme leader for
Physiotherapy, University of
Huddersfield, Huddersfield, UK
35: Musculoskeletal problems of
upper limb; 36: Musculoskeletal
problems of lower limb
Dr Lorraine Graham
Lead Consultant in Amputee
Rehabilitation Medicine,
Musgrave Park Hospital, Belfast,
Northern Ireland, UK
41: Amputee rehabilitation
Ms Alison Howle
Speech and Language Therapist,
Westmead Hospital, Westmead,
New South Wales, Australia
8: Speech and language;
9: Swallowing
 Contributors
xvi
Ms Trina Phuah
Lecturer in Occupational
Therapy, School of Community
Health, Charles Sturt University,
Albury, New South Wales,
Australia
23: Technical aids and assistive
technology
Dr Ng Yee Sien
Senior Consultant in
Rehabilitation Medicine,
Singapore General Hospital,
Singapore
39: Geriatric rehabilitation
Mrs Alison Smith
Rehabilitation Nurse
Specialist, University Hospitals
of Derby and Burton
Foundation NHS Trust,
Derby, UK
29: Multiple sclerosis
Dr Matthew Smith
Consultant in Rehabilitation
Medicine, Leeds General
Infirmary, Leeds, UK
28: Stroke
Mr Matthew Sproats
Head of Department,
Occupational Therapy,
Westmead & Auburn Hospitals,
Western Sydney Local Health
District, New South Wales,
Australia
21: Orthotics and prosthesis
Professor Rod Taylor
Chair of Health Services
Research and Academic Lead,
Exeter Clinical Trials Support
Network; and NIHR Senior
Investigator, University of Exeter
Medical School, Exeter, UK
16: Cardiac rehabilitation
 Section 1

Common clinical
approaches

1 Concepts of 14 Skin problems 195

rehabilitation 3 15 Injections in
2 Epidemiology 21 rehabilitation
3 Rehabilitation medicine 203
team 37 16 Cardiac
4 Organization of rehabilitation 213
services 47 17 Respiratory
5 History and issues in
examination 63 rehabilitation 233
6 Rehabilitation 18 Mobility and
assessment and gait 251
evaluation 77 19 Family and
7 Cognition and relationships 269
behaviour 89 20 Vocational
8 Communication rehabilitation 279
105 21 Orthotics 289
9 Swallowing 113 22 Wheelchairs and
10 Spasticity and seating 305
contractures 123 23 Technical aids
11 Chronic pain 141 and assistive
technology 319
12 Neurogenic
bladder and 24 Personal factors in
bowel 167 rehabilitation 339
13 Sexual 25 Rehabilitation in
function 181 critical illness 347
 Chapter 1 3

Concepts of rehabilitation
Introduction 4
Models of disability 5
Terminology 9
Approaches to rehabilitation 10
Goals and habits 12
Outcome measurement 14
Benefits of rehabilitation 16
Summary 18
References 19
Further reading 19
4 Chapter 1 Concepts of rehabilitation

Introduction
There is a lot of variation in what people understand by ‘rehabilitation’. This
is probably due to the perspective they are coming from and the system
or setting in which rehabilitation might occur. The origins of the word are
thought to be from the Latin noun ‘habilitas’, meaning ability, skill, or apti-
tude, adjective ‘habilis’ meaning skilful, capable, and verb ‘habilitare’, meaning
to enable. This chapter focuses on the concepts behind rehabilitation and
rehabilitation medicine, and how these concepts are operationalized.
In healthcare, rehabilitation has been defined as ‘a general health strategy
with the aim of enabling persons with health conditions experiencing, or
likely to experience, disability to achieve and maintain optimal functioning’1.
This means that an understanding of the concepts of disability and of op-
timal functioning are central to understanding the concept of rehabilitation,
and are described later in this chapter. In addition, several models of dis-
ability exist and will also be described. ‘Optimal functioning’ is a less well-​
defined phrase—​for the purposes of this handbook, it is taken to mean not
just a utilitarian concept of functioning but an engagement of the individual
in life in an autonomous way. Importantly, this differentiates a person’s
ability to perform activities useful to self or society from their ability to
meaningfully engage in life in their chosen way. This difference can become
crucially important in those who have lost physical and cognitive abilities.
The World Health Organization (WHO) International Classification of
Functioning, Disability and Health (ICF), described later in this chapter, a
concept that serves as a theoretical underpinning for rehabilitation, makes
this apparent through the description of ‘participation’.
Rehabilitation, specialist rehabilitation, and rehabilitation medicine are dif-
ferent, but related, concepts that are relevant to the content of this hand-
book. Rehabilitation, as an overall term, covers aspects of healthcare that
any healthcare practitioner can and should engage in, as it leads to interven-
tion being made with a purpose in mind that includes optimal functioning in
its widest sense, and not just the management of a specific impairment. For
example, it is the difference between optimum control of a person’s asthma
enabling them to work and participate in sport, rather than merely maxi-
mizing peak flow readings. Specialist rehabilitation often describes a more
complex situation, where multiple factors impact rehabilitation across sim-
ultaneous and diverse rehabilitation goals. Of necessity, this ‘complex’ re-
habilitation requires different healthcare professionals working as a team to
achieve optimum outcomes. Rehabilitation medicine describes the medical
specialty driven by this more sophisticated rehabilitation philosophy, rather
than using an organ-​based, medical model. Rehabilitation medicine works
across the whole spectrum, from specialist rehabilitation through to having
a basic rehabilitation role and possibly an educational role in enabling any
type of rehabilitation to occur. Rehabilitation medicine has similarities to
specialities which cover a specific phase of life or disease trajectory, such
as palliative care, but differs in that rehabilitation can be part of condition
management at any time.
 Models of disability 5

Models of disability
Traditional biomedical model
The biomedical model of disability is focused on pathology and impair-
ment. It assumes several unhelpful notions about the nature of disability
(Box 1.1).2
The philosophy of Western medicine has traditionally been to treat and
to cure, but in rehabilitation these outcomes are unlikely and the aim has
often been to ‘normalize’. This philosophy was reinforced by the initial
WHO classification that produced a distinction between impairment, dis-
ability, and handicap. The biomedical model of disability usually implies that
the physician takes a leading role in the entire rehabilitation process—​being
team leader, organizing programmes of care, and generally directing the
delivery of services for the person with disabilities. The doctor/​patient re-
lationship was the senior relationship in the medical model. Rehabilitation
was born around the time of the First World War when there was a strong
philosophy of the doctor telling injured servicemen how to behave, how to
get better, and how to get back as quickly as possible to active duty. Such a
model may have been appropriate in that cultural context but not in wider
society today.
Social model of disability
The social model of disability understands disability as secondary to the so-
cial, legislative, and attitudinal environment in which the person lives and not
any underlying medical condition. Although a person’s abilities may be dif-
ferent, the disability is because society either actively discriminates against
the person with a disability or it fails to account for their different needs.
The key features of the social model are listed in Box 1.2.2
Biopsychosocial model of disability
The biopsychosocial model of disability is an attempt to account for both
the social and biomedical models of disability. The WHO ICF3 uses the
biopsychosocial model. There is controversy over this approach, and some
who use the social model of disability disagree with approaches that include

Box 1.1 Unhelpful assumptions of the medical model

of disability
• Disability is regarded as a disease state that is located within an
individual: the problem and solution are found solely within that
person.
• Disability is a deviation from the norm that inherently necessitates
some form of treatment or cure.
• Being disabled, a person is regarded as biologically or psychologically
inferior to those who are able-​bodied and ‘normal’.
• Disability is viewed as a personal tragedy. It assumes the presence of a
victim. The objective normality state that is assumed by professionals
gives them a dominant decision-​making role often noted in a typical
doctor/​patient relationship.
6 Chapter 1 Concepts of rehabilitation

Box 1.2 Assumptions of the social model of disability

• A person’s impairment is not the cause of restriction of activity.
• The cause of restriction is the organization of society.
• Society discriminates against people with disabilities.
• Attitudinal, sensory, architectural, and economic barriers are of equal,
if not greater, importance than health barriers.
• Less emphasis is placed on the involvement of health professionals in
the life of the person with disabilities.

aspects of health within a model of disability, as they would define disability

as being solely due to a lack of response in changing the environment to
accommodate the needs of the person. There are weaknesses in the ICF
model, principally around personal context and well-​being, and philoso-
phies around the biopsychosocial model are still developing.4,5
The definitions used in the ICF are shown in Box 1.33 and described in the
following paragraphs.
Impairment is a medically descriptive term that says nothing about con-
sequence. For example, a right hemiparesis, a left-​sided sensory loss, and
a homonymous hemianopia are all impairments but the consequences of
each of these will depend on many other factors, such as the person’s en-
vironment, their job, family role, lifestyle, and expectations.
Activity describes the everyday tasks that any person, wherever they live,
would be expected to do as a basic part of life, for instance, walking or
eating. There is an overlap with participation and there is a judgement in-
volved in relation to societal norms as to what these everyday tasks are.
Participation is defined as involvement in a life situation. It will vary con-
siderably between people, for instance, having a mild right hemiparesis may
have profound implications for a young person wanting to join the armed
forces, as such occupations may be closed to him/​her or an existing job
may be lost. However, for a retired person with comorbidities, a similar

Box 1.3 International Classification of Functioning,

Disability and Health
• Impairment: loss or abnormality of a body structure or of a
physiological or psychological function.
• Activity: the execution of a task or action by an individual. Thus,
activity limitations are difficulties an individual may have in executing
activities.
• Participation: involvement in a life situation and thus participation
restrictions are problems an individual may experience in such
involvement.
• Contextual factors: includes the features, aspects, and attributes of, or
objects, structures, human-​made organizations, service provision, and
agencies in, the physical, social, and attitudinal environment in which
the people live and conduct their lives. Contextual factors include
both environmental and personal factors.
 Models of disability 7

impairment may have no perceptible impact on lifestyle. Participation is

often optimized by changing environmental factors, for example, a recep-
tionist with a hemiparesis remains capable of undertaking the job and being
a valuable member of the workforce if appropriate modifications are made
to IT equipment. Another example is a person who needs to use a wheel-
chair but cannot move around the office because it is not wheelchair ac-
cessible. In both cases, the employer’s attitude may cause the person to
be moved elsewhere or even lose their job. The change necessary here is
attitudinal, legislative, or both. Therefore, rehabilitation includes addressing
aspects such as societal attitudes and the physical environment, which
are traditionally outside the realm of medicine. A rehabilitation medicine
doctor would not undertake that change themselves, as that is not where
their skills lie. However, part of their duty is to identify the issue, give ap-
propriate information, and send appropriate referrals to advocate on the
patient’s behalf.
The full ICF is a detailed and lengthy document. The ICF recognizes the
importance not only of describing the functioning of an individual but also
placing such functioning into its social context. Fig. 1.1 is reproduced from
the WHO website and provides a useful summary.
Rehabilitation medicine focuses not on the impairments and patholo-
gies, but rather on activity and participation, attempting to optimize these
according to what is felt to be important by the individual involved. This
is operationalized by identifying the aims or goals the person may have
(E see ‘Goals and habits’). This may include addressing aspects of path-
ology and impairment, but the overall aim or goal is at the level of activity

Health condition
(disorder or disease)

Body functions
Activities Participation
and structures

Environmental Personal
factors factors

Fig. 1.1 Interactions between the components of the ICF.

Reproduced with permission from World Health Organization (WHO). International Classification
of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health Organization.
Copyright © 2018 WHO. www.who.int/​classifications/​icf [accessed 05/​11/​2018].
8 Chapter 1 Concepts of rehabilitation

or participation. Changing aspects of the environment or the ways in which

a person performs an activity are often the key changes that lead to that
person achieving their goal. Rehabilitation medicine does not minimize the
importance of diagnosis and impairment but sees addressing these as part
of a whole spectrum of ways to achieve a person’s goals. As the primary
skills of a doctor are often in the area of pathology and impairment whereas
those of allied health professionals are more in activity and participation, it
often falls to the doctors within the multidisciplinary team to be the profes-
sionals who are most involved with pathology and impairment, and this can
cause a tendency to revert to the medical model. The skill of a rehabilitation
doctor is dependent on being able to take an informed overview of the
whole ICF spectrum.
At times, a sense of antagonism has existed between health professionals
involved in disability and activists in the disability movement. These two ex-
treme positions have softened over time: people with disabilities realize that
health professionals have a clear and important role in helping to optimise
abilities, while health professionals realize the rights of the person with dis-
abilities to make decisions about their rehabilitation. Nevertheless, it can be
difficult to maintain these ideals in practice. Multidisciplinary rehabilitation is
often based within a healthcare system predominantly using the biomedical
model; coupled with resource constraints, this can lead to focusing on very
narrow aspects of a person’s health.
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 THE STAR-CLUSTER 47 TOUCANI
From Sir John Herschel’s drawing

Smaller than ω Centauri, but even more beautiful in the

telescope, is the cluster 47 Toucani,[10] which to the unaided eye
appears like a fourth-magnitude star near the smaller Cloud of
Magellan. The long curve of Grus followed southwards leads to it.
Nearly as many stars as in ω Centauri, or about 9500, are here
massed into a still smaller space, so the cluster is brighter, and is
“compressed to a blaze of light” at the centre. The two sets of stars,
which are mingled together throughout, are of thirteenth to fifteenth
and of seventeenth magnitudes respectively. Herschel saw the inner
denser part rose-coloured while the outer was white, but the present
writer could not see this nor find anyone to confirm it to-day, possibly
because the refracting telescopes now so often used do not show
colour so well as large reflectors like Herschel’s. A double star of
11th magnitude, which is conspicuous in Herschel’s drawing, is
doubtless far outside the cluster, and only appears projected against
it by perspective.
Near β Aquarii there shines with the light of a sixth-magnitude
star another “magnificent ball of stars” which has been compared to
“a heap of fine sand.” It is named 2 M Aquarii.
Over seventy of these tightly packed balls of stars are known,
even counting only the brightest, and their distribution is rather
curious. A large number (about twenty) occur in the Clouds of
Magellan, and more than half of the seventy are in the Milky Way,
not scattered evenly along its course, but almost if not entirely
confined to its southern part, and chiefly gathered in a great group in
its brightest portion, where it passes through Sagittarius, Ophiuchus,
and Aquila. Here they are mingled with—or perhaps projected
against—numerous stars of the same magnitudes; but many balls
are also found outside the Milky Way, widely scattered, and in these
parts of the sky there are relatively few of the faint-magnitude stars
which compose all the globular clusters. 47 Toucani, for instance,
though it is near the small Magellanic Cloud, stands quite apart from
it, isolated in a black sky.
We do not know the distances of any of these balls of stars.
Those which have been examined spectroscopically shine like
Canopus—that is, they are of a type intermediate between Sirius and
our sun—but the chief light comes, of course, from the brighter stars,
and it may be that the fainter stars mingled with them belong to a
different type.
A remarkable fact lately discovered is that many globular clusters
—but not all—contain a large number of variable stars. These vary in
light in a period of about a day and have a range of about one
magnitude. They are not of the Algol type, nor quite of the usual
“short-period” types, and it is not yet clear what is the cause of
variation, though it seems probable that “cluster-variables” are
double stars.
 XIV
NEBULAE

Athwart the False Cross, from δ Velorum to ι Carinae, a line

passing on leads to the round white spot which we found to be a
star-cluster. A little further in the same direction is a larger curved
white patch, bright enough to be visible, once it is familiar, even after
the moon has risen. This is the Great Nebula in Argo, the Keyhole
Nebula, in which Eta Argūs once blazed out. Even a binocular will
divide it into two parts separated by a chasm, and will show the
pearly background powdered over with many small stars.
But even the most powerful telescopes do not resolve this pale
background into stars, as they resolve the star-cluster just
mentioned: it remains a pearly mist, the brighter part strangely
broken by dark rifts, the fainter, beyond the chasm, a tangled skein
of long cloudy streaks reaching out into the darkness and gradually,
irregularly, fading away.
When Herschel found this background unresolvable into stars, he
concluded that it did not form part of the Milky Way, but was at an
immeasurable distance behind, so that here he was looking right
through the Galaxy at a still more distant region of stars, too distant
and faint for his telescope to distinguish them separately. But the
spectroscope has taught us that these cloud-like nebulae, though
stars are often mingled with them, are not formed of stars at all, but
of inchoate masses of faintly luminous gas; and they cluster so
thickly in the Milky Way, generally avoiding other parts of the sky,
that it seems evident that they lie in it and form part of it. They are
also found in great numbers in the Greater Magellanic Cloud.
If the days of the Herschel’s photography had not come to the aid
of astronomers, and Sir John speaks of the feeling of despair which
often almost overcame him when trying, night after night, to draw the
“endless details” of this nebula, so capricious in their forms are its
curving branches and the dark spaces between, so strangely does
its brightness vary in different regions, and so numerous are the
stars scattered over it. With extraordinary patience he succeeded in
cataloguing the positions of over 1200 of these. To compare the
present aspect of the stars with his catalogue would be a laborious
task, but might lead to results of great value.
The curious dark oval rift in the midst of the bright part, which he
compared with a keyhole, he found to be not entirely devoid of light,
a thin nebulous veil covering part of it; and many of the dark lanes
and holes which in small instruments look perfectly black, are
actually filled with faint stars and extremely faint nebulosity. The
whole region near the nebula is exceedingly rich in stars, and also in
star-clusters, as we have already seen. To quote Herschel once
again:
“Nor is it easy for language to convey a full impression of the
beauty and sublimity of the spectacle it offers when viewed in a
sweep, ushered in as it is by so glorious and innumerable a
procession of stars, to which it forms a sort of climax, justifying
expressions which, though I find them written in my journal, in the
excitement of the moment, would be thought extravagant if conveyed
to these pages. In fact, it is impossible for anyone with the least
spark of astronomical enthusiasm about him to pass soberly in
review, with a powerful telescope and in a fine night, that portion of
the southern sky ... such are the variety and interest of the objects
he will encounter, and such the dazzling richness of the starry
ground on which they are presented to his gaze.”
In the constellation of the Sword-fish, on the edge of the Great
Cloud of Magellan, is another nebula, 30 Doradūs, the Great Looped
Nebula, which is even more marvellous in complexity of structure
than the Keyhole Nebula in Argo. No photograph can reproduce, and
no words can describe, the filmy appearance of these nebulae as
seen in a telescope. The Looped Nebula seems to consist entirely of
strangely curved and twisted streamers on a background of dark sky,
with a few sparkling stars of various brightness scattered over it. At
the complicated centre one of the loops forms a nearly perfect figure-
of-eight, and another takes the outline of an eye.
Brightest of all the large gaseous nebulae is the well-known Orion
Nebula, in the sword of the giant. A 3-inch telescope shows the main
features well, the dark bay running into its brightest region, the row
of three brilliant stars and the “trapezium” of four tiny ones very close
together, and the long outlying branches which have such fantastic
curves. Because of its comparative brightness, its entrancing beauty,
and its position where it can be seen from all latitudes, this nebula
has been studied more than any other. The first drawing of it was
made in 1656, the first photograph in 1880. It remains a baffling
mystery still, but a few facts have emerged.
Its distance is immeasurable: it has been guessed at a thousand
light-years. It must, therefore, be inconceivably vast in extent, but it
is probably excessively tenuous, like a comet’s tail, of which a million
miles contain a negligible amount of matter. It is almost stationary in
space, and a careful study of its form since 1758 proves that there
has been no visible change, except perhaps in the relative
brightness of some of its parts. Yet a recent spectroscopic
investigation shows that movements are taking place in different
directions within the nebula, and a slow rotation of the whole mass,
or of its brightest portion, is suggested.
It is composed of faintly luminous gas, though whether it glows
from heat or from some other cause we do not know. Photographs of
nebulae are very misleading with regard to brightness: one must
remember that they have often been exposed for many hours.
Helium, hydrogen, and an unknown gas which we call nebulium are
mingled together, but not in equal quantities. In some of the fainter
regions of the nebula, especially on the south and west borders,
hydrogen produces a great deal of the light; in the brightest parts,
near the trapezium, the glow of nebulium is much more prominent.
It is scarcely doubtful that many of the stars which appear to be
involved in the nebula are physically connected with it, especially
since they are of a type frequently found near nebulae, viz. very blue
Orion-type stars with some of their hydrogen lines not dark but
bright, as in the nebula.
The southern hemisphere is rich in nebulae smaller but of the
same kind as these three magnificent objects, the Keyhole, the
Looped, and the Orion Nebulae—that is, large irregular masses of
gas, often spangled with stars—and each has some special beauty
of its own; but for most of them large telescopes are needed to grasp
the faint details. There is a nest of them in the northern part of
Sagittarius: a cloudy streak visible to the naked eye, a little north of
the star γ Sagittarii, represents three nebulae and clusters close
together—M 8, M 20, and M 21. The first is a wonderful combination
of a bright scattered star-cluster and a gaseous nebula, with dark
rifts dividing the cloudy structure. The second is the celebrated Trifid
Nebula, less bright and large, but with even more striking black lanes
which split the principal part into three almost separate portions.
Many faint stars are scattered over it, but as they are scarcely more
numerous than in the surrounding regions, most of them probably
are not connected with the nebula. M 21 is a star-cluster.
Near these, where Sagittarius borders on Aquila,[11] is a small but
very remarkable nebula, known from its shape as the Horseshoe or
the Omega Nebula (M 17). It has a curious mottled appearance, with
bright knots here and there.
And a little further west, near together, are two wonderful nebulae
which surround the two stars Rho Ophiuchi and Nu Scorpii.
Professor Barnard, who has studied and taken exquisite
photographs of many nebulae, considers the first of these the finest
in the sky, because of its dark, winding lanes and the veiling of the
stars in places by partly transparent nebulous matter.
 XV
OTHER TYPES OF NEBULAE

The large irregular nebulae described in the last chapter are all
more or less mingled with stars, at least in appearance, and it has
been suggested that they are star-clusters in process of formation,
with larger and brighter masses of filmy nebulosity all about them
than at later stages, for long-exposure photographs reveal some
exceedingly faint nebulosities surrounding Kappa Crucis and the
Pleiades and other fully-developed star-clusters. But this can only be
a guess until we know more about the nature of nebulae. In some
regions of the sky we find vast spaces thinly veiled by nebulosity so
faint and transparent that it seems to have reached the very limit at
which matter can exist and be recognised as such. Thus in the
constellation of Orion nearly all the bright stars are connected
together by the vast convolutions of an exceedingly faint diffused
nebula in spiral form, the innermost curve of which ends in the Great
Nebula of the Sword, and the whole region within is filled with faint
light.
Quite distinct from these nebulae are others of perfectly regular
form, very small, purely gaseous, without intermingling of any stars,
but usually with one bright star-like nucleus at the centre. One form
is the ring nebula, of which much the best known is that in the
northern constellation of the Lyre. There are, however, some in the
south. In a large telescope they appear like little golden wedding-
rings against the dark sky background.
Another regular form is the “planetary nebula,” so called because
they look much like planets in large telescopes, being perfectly round
or oval with a sharply-defined edge, and in several cases there are
handle-like appendages, which may possibly be encircling rings, like
the rings of Saturn. These nebulae shine with a peculiar bluish-green
light, the colour of the unknown gas nebulium, of which they are
chiefly composed. In Hydra, south of the star Mu, is one of the
brightest and largest, known as H 27—that is, No. 27 on William
Herschel’s list. It is elliptical and of a lovely bluish colour, with a
bright nucleus exactly in the centre.
By means of these sharply-defined central nuclei it has been
found possible to measure the approaching or receding movements
of these nebulae, and although the one just mentioned is receding
from us with a speed of only 3½ miles a second, their average speed
is high, amounting to 40 or 50 miles a second. One in Sagittarius is
receding at more than 80 miles a second, and another in Lupus
attains a speed of over a hundred.
These are movements comparable with those of stars, but the
average is higher than even for the most rapidly moving class of
stars, the red-solar and Antarians. May we, then, place the planetary
nebulae at the end of our star-series, since we saw that from the
blue down to the red the average movements became faster and
faster, and may we believe that all stars eventually become gaseous
nebulae, as “new stars” seem to do? But we saw that in spectrum
these nebulae rather resemble the stars at the other end of the
series, the Wolf-Rayet, which lead directly to the hottest and
brightest of all, the Orion stars. Planetary nebulae also resemble
Wolf-Rayet, Orion, and Sirian stars, and differ from solar and red
stars in that they cluster near the Milky Way, and are scarcely ever
found far from it. Their place in the universe cannot be established
yet.
One more kind of nebula, the most numerous of all, remains to
be mentioned, the so-called “white nebulae,” which do not glow
green like many of the brighter planetaries, but shine with a white
light and have more or less star-like spectra, although not even the
most powerful telescopes can resolve the white cloudiness into
stars. The typical nebula of this class is the famous Andromeda
Nebula, visible to the naked eye in northern skies as a large oval
spot shining softly “like a candle shining through horn.” Photography
first disclosed the remarkable fact that it has the form of a great,
closely-wound spiral, and further research has shown that by far the
greater number of “white nebulae” have this form. There is a very
fine one in Aquarius,[12] which has been known since 1824, but
visual observations gave absolutely no idea of its true form. A
photograph exposed for four hours in September 1912 showed it
clearly as about two turns of a great spiral.
The distribution of this kind of nebula is quite different from that of
the gaseous nebulae, for, instead of clustering towards the Milky
Way, they avoid it, and especially the brightest region, where we saw
that the others most abound, viz. in Scorpio, Sagittarius, and
Ophiuchus. On the contrary, the largest number of these is found
near the north pole of the Galaxy—that is, as far removed from it as
possible, in Virgo. There is, however, no corresponding group about
the south pole of the Galaxy.
One investigator has found the distance of the Andromeda
Nebula to be twenty light-years, but the distance and the movements
of this type are difficult to discover. They are evidently very different
from the others, and quite as mysterious.
 XVI
THE CLOUDS OF MAGELLAN

One of the wonders which most attracted the attention of early

explorers in the southern hemisphere, and roused as much interest
as the Southern Cross, was the pair of faint clouds, looking like
detached pieces of the Milky Way, which are seen in the
neighbourhood of the South Pole. Marco Polo made a sketch of the
Greater Cloud, which he describes wonderingly as “a star as big as a
sack.”
Although some star-maps show short branches of Milky Way
pointing towards the two Clouds, this is incorrect, and they are quite
separate from it. Herschel was struck by their isolation, especially in
the case of the Little Cloud, which he described as situated in a
“most oppressively desolate desert,” its only neighbour being the
globular cluster 47 Toucani, which is near, but separated by a
perfectly black sky.
The Greater Cloud is much brighter to the naked eye than the
Lesser, and it is much more complex and interesting in the
telescope. It contains, moreover, the wonderful Looped Nebula, of
which we have already spoken.
Both Clouds consist of gaseous nebulae and star-clusters on a
background of vague nebulosity and crowds of almost
indistinguishable stars. But the white nebulae shun the Clouds, just
as they shun the Milky Way.
An immense number of variable stars have been discovered in
the Clouds of Magellan, of the same type as those in globular
clusters. Miss Leavitt of Harvard Observatory catalogued from
photographs no less than 969 in the Lesser Cloud and 800 in the
Greater. In the latter the greatest number of variables was found in a
stream of faint stars which connects a group of star-clusters with the
Looped Nebula, and others occur locally in certain parts of the
Cloud, but few are in its northern region or in parts where many of
the brighter stars congregate. All the variables are very faint, the
usual minimum in both Clouds being about fourteenth magnitude,
and the maximum seldom more than one magnitude brighter. A few
in the Lesser Cloud have been found with periods unusually long for
this “cluster type” of variables, amounting to 32, 66, and even 127
days. These longer periods seem to belong to somewhat brighter
stars, but they are quite as exact as the usual period of a few days or
a single day.
 XVII
THE MILKY WAY

Like a great river returning into itself, the Galaxy encircles the
starry heavens, and those who know only its northern course have
no idea of its brilliance and wonderful complexity in its brightest part.
Its light is soft, milky, and almost uniform, between Cygnus and
Sirius, but when it enters Argo it becomes extremely broad, and
spreads out like a river on a flat marshy plain, in many twisting
channels with spaces between. Where Canopus shines on the bank
there is a narrow winding ford right across its whole breadth, as if a
path had been made by the crossing of a star.
After this it suddenly becomes extremely narrow, but so bright
that all the light which was shining in the broad channel seems to be
condensed in this narrow bed. In the brightest, richest part the Great
Nebula of Argo is easily distinguished by the naked eye. Contrasting
with this and other bright condensations are black gaps, the largest
and blackest of which is the well-known Coal-Sack near the
Southern Cross.
 THE MILKY WAY IN SCORPIO, LUPUS,
AND ARA
Photographed at Hanover, Cape Colony,
by Bailey and Schultz

The river now divides. One short stream, which goes north from
Centaur towards Antares, is faint and soon lost; but another northern
stream is so bright and so persistent that from Centaur to Cygnus we
may say that the Galaxy flows in a double current. This northern
portion forms first the smoke of the Altar on which the Centaur is
about to offer the Beast, then passes through the Scorpion into the
Serpent-Holder, and here, between η Ophiuchi and Corona Australis,
the double stream has its greatest width. The northern division soon
grows dim and seems to die out, but begins again near β Ophiuchi,
and, curving through a little group of stars, passes through the head
of the Eagle and forms an oval lagoon in the Swan.
The southern stream passes through the Scorpion’s Tail into
Sagittarius, then through the Eagle and the Arrow till it flows close
beside the northern stream in the Swan, and finally rejoins it in a
bright patch round α Cygni. Except just here it is much brighter than
the northern stream, and its structure is even fuller of wonderful
detail than in Argo. In Sagittarius it consists of great rounded patches
with dark spaces between. The brightest of these contains the star γ
Sagittarii; then follows a remarkable region of small patches and
streaks, the portion passing through Sagittarius and Aquila being
thickly studded with nebulae. This is followed by another bright
patch, rivalling that round γ Sagittarii, which involves the stars λ and
6 Aquilae.
This ends the most brilliant and wonderful part of the Milky Way.
When well seen, as we see it in the south, it recalls Herschel’s
words, written at the Cape when it came into view in his telescope:
“The real Milky Way is just come on in great semi-nebulous
masses, running into one another, heaps on heaps.” And again: “The
Milky Way is like sand, not strewed evenly as with a sieve, but as if
flung down by handfuls, and both hands at once.”
What is it? The ancients thought it the pathway of departed
spirits, or fiery exhalations from the earth imprisoned in the skies, or
a former road of the sun through the stars. But Democritus and some
other inquiring Greeks believed it to be the shining of multitudes of
stars too faint and too close together to be seen separately, and we
know this to be the truth. We know also, from simply counting the
stars in different regions of the sky, that their numbers increase
regularly as we go from north or south towards the Milky Way, and
stars of all magnitudes are most abundant within its course. We saw
also that star-clusters and certain kinds of nebulae frequent it, while
other kinds avoid it, and that blue and white stars are the most
abundant near it, and tend to move through space in planes parallel
with it, while the redder stars are scattered and move about in all
directions.
Facts like these lead astronomers to believe that the Milky Way
has a definite relation with all the visible universe, that even the most
distant nebula is not an outlying universe apart from ours, but all are
parts of one vast stellar system.
It is possible that the Milky Way, which we see as a great circle,
double in one part, is really an immense spiral, and that we are
nearest one curve of it, the great southern division which looks so
bright. It may be that the spiral nebulae, vast though they are in
terms of earthly measurement, are tiny models of one tremendous
spiral which enfolds the universe with its coils.

PRINTED IN GREAT BRITAIN

BY BALLANTYNE, HANSON & CO. LTD.
EDINBURGH AND LONDON

Footnotes:
[1] Published at 5s. by Gall & Inglis, Edinburgh and London.
[2] Stars are classified by astronomers in “magnitudes,” i.e.
degrees of brightness, those of first magnitude being the
brightest. Stars below sixth magnitude cannot be seen with the
naked eye.
[3] Compare Aratus:

“The Virgin and the Claws, the Scorpion,

The Archer and the Goat.”

[4] Right ascension in the skies corresponds with longitude on

earth, but is more often reckoned in time than in degrees. For
instance, R.A. 1 hour 35 minutes, the right ascension of Achernar,
means that this star will be on the meridian 1 hour 35 minutes
later than the “first point of Aries”—that is, the point at which the
equator cuts the ecliptic at the spring equinox, the fundamental
point corresponding with Greenwich in earthly longitude.
[5] The stars ε and ι Carinae, κ and δ Velorum, form a cross much
like the Southern Cross, but less bright, and this is called the
False Cross.
[6] A “binary” is a system of two stars which are known to be
comparatively close together and influencing one another’s
movements. A “double star” may be a binary, or the two stars may
really be very far apart and have no connection, merely
happening to lie one nearly behind the other.
[7] Now often called Eta Carinae, since Argo has been subdivided
(see p. 7).
[8] It is easy to remember the names of the stars in the Southern
Cross. Begin at the foot, which is obviously the brightest, and
count round the Cross in clockwise direction α, β, γ, δ. κ is
beyond β in a line with γ, β.
[9] These two astronomers observed at Paramatta, New South
Wales, in the early part of the nineteenth century.
[10] Also named ξ Toucani.
[11] On Scutum in maps where this constellation is not included in
Aquila.
[12] N. G. C. 7293.
 Transcriber’s Notes:

The illustrations and footnotes have been moved so that they do not break up
paragraphs and so that they are next to the text they illustrate.
Typographical and punctuation errors have been silently corrected.
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