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Important Context for Counselling People With Physical and Neurological Conditions

People with physical disabilities and neurological disorders and diseases have the same range of interests, talents, aspirations, and concerns as any other group. While they face limitations, accommodations can be made for most people with these issues.

Physical disabilities and neurological disorders and diseases can take a variety of forms. The most common relate to mobility, agility, pain, and sensory input.

Types of physical disabilities

The following sections define and briefly describe a range of physical disabilities.

Hearing

Terms to describe hearing loss are as much sociological as medical. For example:

  • People who are hard of hearing have a degree of residual hearing. Whether their hearing loss is mild, moderate, severe, or profound, they strive to participate in the hearing community. They may learn to Sign or read lips; they may also use hearing aids or cochlear implants. They may be called “oral deaf.”
  • People who are culturally Deaf identify with and participate in Deaf culture. They do not perceive of deafness as a disability, but as the basis of a distinct cultural group. They Sign with American Sign Language (ASL) or Langue des signes Québécoise (LSQ) if they are francophone. They may read lips but may not speak orally or use assistive devices. They are also called “manual deaf” or “signing deaf.”
  • People who are deafened (or “late-deafened”) have lost their hearing later in life. They tend not to identify with either the hard of hearing or culturally Deaf communities.

When working with people who are hard of hearing, keep in mind that earing aids may be fine one-on-one. But in a group of people, the user may only hear portions of words.

When working with anyone with hearing loss, avoid the terms hearing impaired, hearing disabled, and hearing handicapped. They have a negative connotation because they focus on what’s missing. Never use deaf-mute, which may be inaccurate, or deaf and dumb, which is offensive.

Sight

The term visual impairment includes:

  • Blindness, which is an inability to see anything. This might result from damage to the eyes caused by injury or illness. Or it might be a neurological problem called cortical or cerebral vision impairment (CVI). In CVI, the eyes may be healthy, but the brain is unable to interpret visual information. CVI is the leading cause of blindness in children.
  • Low vision, which is vision loss that can’t be corrected with lenses, drugs, or surgery. It is caused by eye diseases such as glaucoma, cataracts, macular degeneration, or diabetic retinopathy. It occurs mostly in adults and interferes with daily activities. An optometrist or ophthalmologist who specializes in functional eye exams provides the diagnosis. People with low vision may still have some useful sight.
  • Legal blindness, which is assessed using standard eye tests. It measures visual clarity and field of vision numerically and with corrective lenses. Normal clarity is 20/20. Field of vision, which measures everything a person can see without moving their head, is normally 100 degrees; anything less is sometimes called tunnel vision. With corrective lenses, a person who is legally blind has visual acuity of 20/200 or less and a field of vision measuring 20 degrees or less. Legal blindness determines whether a person can do certain things, such as driving, and whether they qualify for government support.

Any vision loss that can be corrected to 20/20 vision with glasses is not considered a visual impairment. A person who has lost an eye may struggle with depth perception without being legally blind. People with colour blindness or impaired night vision may be restricted from some activities, such as flying a plane, without being legally blind.

Mobility

Mobility refers to a person's ability to move. Mobility is important to health, especially as people age. Mobility keeps the cardiovascular system healthy, providing protection against heart disease. Decreased mobility leads to tightened muscles, reduced flexibility, and decreased range of motion. This increases risk for injury. Poor mobility can decrease enjoyment of life and increase risk of depression and anxiety.

People may have mobility limitations due to accidental injury or congenital problems. Mobility impairments can result from diseases such as arthritis, multiple sclerosis, cerebral palsy, spina bifida, diabetes, muscular dystrophy, and paraplegia. Impaired mobility can even arise from limited mobility: sitting too much of the time can lead to back and leg pain, which can impair mobility further!

Not all mobility impairments are obvious. Some people may use assistive devices, such as a wheelchair, crutches, a cane, or a walker, all the time. Others may be able to walk short distances but need a scooter for longer distances. Lack of mobility can also affect the upper body. A person may have no problem walking but be unable to lift their arms over their head or have limited range of motion in their neck.

In employment counselling, all types and degrees of mobility impairment must be considered. Accommodations need not be complicated or costly. Perhaps a desk simply needs be positioned close to an exit or tasks that involve lifting can be given to someone else.

Chronic pain

Chronic pain is any pain that goes on longer than 3 months. It is one of the most prevalent health problems in the world. Nearly 20% of Canadian adults experience chronic pain. It can include headaches, back pain, joint pain, and internal pain. It can be caused by injury or by illness, such as arthritis, Crohn’s disease, fibromyalgia, or cancer. It is more common in women than men, and more likely to occur with age.

Chronic pain can be comorbid with many other disabling conditions. For example, people can develop depression because they’re unable to do things they used to enjoy. They can develop anxiety over what will trigger the pain next. They can reduce movement to avoid the pain, which can lead to mobility impairments and increase their risk of injury, depression, and anxiety.

One of the most difficult aspects of chronic pain is that it’s invisible. Others don’t always believe that people are in pain. They might think a person is faking pain behaviours for attention or to get out of work. Or they might think that the person doesn’t have pain because they don’t look as if they’re in pain all the time.

This is especially true when X-rays, CT scans, and MRIs do not show a clear cause for the pain. But research now shows that all pain occurs in the brain, not where it is felt in the body. And brain scans show that, when a person reports chronic pain, the part of the brain that is responsible for pain “lights up.”

Some day, this type of research may help people with chronic pain. For now, the best way to help clients with chronic pain is to believe them and support them in their efforts to find employment that will accommodate their pain impairments.

Autoimmune diseases

In people with autoimmune diseases, the body’s immune system identifies healthy cells as foreign bodies and attacks them. Researchers have identified at least 80 autoimmune diseases. They can be organ-specific or non-organ-specific. Examples of organ-specific autoimmune diseases include:

  • Graves’ disease, which affects the thyroid gland
  • Type 1 diabetes, which affects the pancreas
  • Psoriasis, which affects the skin
  • Inflammatory bowel disease (IBD), which affects the intestines
  • Multiple sclerosis, which affects the nervous system

Examples of non-organ-specific autoimmune diseases include:

  • Rheumatoid arthritis, which affects the joints and can also impact the eyes, lungs, and heart
  • Lupus, which affects connective tissue and can strike any organ system in the body
  • Fibromyalgia, which causes pain all over the body as well as problems with fatigue, sleep, mood, and memory

As well as organ-specific symptoms, like scaly skin with psoriasis and diarrhea with IBD, autoimmune diseases can affect a person’s energy level, strength, and ability to focus. And like chronic pain, these disabilities are not always visible.

One of many ways to accommodate people with autoimmune diseases is with remote work. This allows people to schedule their work for when they’re most alert and take breaks when their energy drops. It can also eliminate tiring commutes.  

Types of neurological disorders

Neurological diseases, disorders, and injuries are a leading cause of disability in Canada. Very few neurological conditions are curable, and many get worse over time. They produce a range of symptoms and limitations that pose daily challenges to people and their families.

As the brain is the control centre for the whole body, there is much crossover between neurological disorders and other issues. For example, acquired brain injury (ABI) can cause motor problems and can therefore be both physical and neurological. Attention deficit hyperactivity disorder (ADHD) is both a developmental and a neurological disorder.

Acquired brain injury

Acquired brain injury (ABI) can be organic or traumatic. An organic brain injury may be caused by a stroke, tumour, aneurysm (blood clot), infection, or illness. A traumatic brain injury (TBI) may be caused by one or more blows to the head, surgery, electrocution, or substance abuse.

Brain injuries develop over time. This may be the result of a degenerative disease such as Parkinson’s or Alzheimer’s, ongoing substance abuse, or mild traumatic brain injury (MTBI). Repeated MTBI, such as seen in some athletes, may cause chronic traumatic encephalopathy (CTE), a condition like Alzheimer’s. But even a single MTBI can cause lasting symptoms in up to 20% of survivors.

Some people may have a TBI that appears severe, yet they recover quite quickly. Other people might not even know they’ve been injured right away. For example, any hyperflexion-hyperextension injury (whiplash) can cause a traumatic brain injury without an external blow to the head. Symptoms such as vomiting, dizziness, and headaches may not arise until hours, days, or even weeks later.

It might be that current imaging technology is not refined enough to show the severity of an injury at a microscopic level. And microscopic injury to the body’s control centre might be all that’s needed to cause lasting disability. For these reasons, experts are less and less inclined to classify brain injury as mild, moderate, or severe.

Problems resulting from a brain injury can include:

  • Cognition. There may be memory loss, thinking may feel slow, the client may describe the way they feel as “brain fog.”
  • Sensory processing. Light may seem too bright, sounds may seem too loud, smells may trigger nausea, a variety of stimuli at once may feel overwhelming.
  • Vision. Physical damage to the vision system may trigger severe headaches when reading, driving, or using electronics.
  • Communication. The client may have difficulty understanding what people are saying or “finding” words to use in response.
  • Behaviour or mental health. Clients may experience depression or anxiety, be irritable or easily angered, act out, or be socially inappropriate.
  • Fatigue. Because the brain never stops working and the injured brain must work harder at everything, clients may feel exhausted all the time.

The biggest issue for many people with ABI is that their issues may not be visible. They may not be believed. They may be pushed back to work too soon. Employers may avoid accommodating issues they can’t see, even though they might deteriorate over time.

Clients with symptoms at the milder end of the spectrum may develop strategies to manage cognitive and sensory issues and fatigue. Clients with chronic pain might benefit from pain management protocols. Clients with mental health issues might try medication and psychotherapy. Clients with vision problems should see an optometrist or ophthalmologist trained in neurologically based vision impairments. All clients with ABI need to know they are believed and supported.

Seizure disorders

A seizure is an abnormal electrical discharge that interrupts normal brain function. Recurrent seizures can occur as a single condition called epilepsy or accompany other conditions affecting the brain, such as autism and ABI.

Different stimuli can trigger seizures, which may present in different ways. For example:

  • Generalized-onset seizures originate in both hemispheres of the brain. They cause loss of awareness and sometimes loss of consciousness. They can be motor (involving movement) or non-motor (the person is simply “absent” for a time). They can start and end suddenly.
  • Focal-onset seizures originate in one hemisphere. They may be localized or widely distributed. People may be fully aware during the seizure or awareness may be impaired for some of the seizure or throughout. The seizure may involve repeated, coordinated motor activity (such as pedalling or thrashing). They may be atonic (loss of muscle tone), clonic (rhythmic jerking), myoclonic (irregular jerking), or tonic (sustained stiffening).
  • Seizures may be described as unknown-onset seizures until their cause, triggers, and nature are known.

Some patients experience aura before a seizure. This warning system can include strange sensory issues such as abnormal smells or a sensation of fear. A seizure may be followed by deep sleep, headache, confusion, and muscle soreness.

People with seizure disorders may be limited in their work options by safety concerns. For example, they may not be able to get a driver’s licence or operate machinery. Work limitations may also arise from side effects of anti-seizure medications. These drugs may impair balance, energy, mood, memory, mental acuity, or ability to function under stress. However, well over 90% of jobs should not be limited by the effects of epilepsy.

Some people with seizure disorders use seizure-alert dogs (SAD). Some dogs can smell bodily chemicals released from a few seconds to 45 minutes before a seizure. Some of these dogs can be trained to display behaviours that alert their human to get to a safe place. They may also be trained to fetch anti-seizure medication and to stay close to their human during the seizure. Some humans can be trained to work with SAD. These dogs are permitted in all the same places as other service dogs. They can help some people, but they are not for everyone.

Tic disorders

Tics are irregular, involuntary, repetitive actions. Motor tics involve movement such as blinking or jerky motions. Verbal tics are vocal outbursts such as grunts, sniffs, or throat clearing. They may be transient (short-lived) or chronic (occuring many times daily for at least 12 months).

Tic disorders most often begin in childhood. Some lessen with age. People who have symptoms after age 18 will likely continue to have them throughout life.

People with tic disorders usually report a powerful urge, something like an itch, when a tic is about to occur. The urge does not go away until they carry out the tic. Tics may get worse due to stress, strong emotions, fatigue, illness, or with extreme temperatures.

The best known and most severe tic disorder is Tourette’s syndrome (TS). TS combines motor and verbal tics. It is also the rarest tic disorder, and usually isn’t as severe as is often depicted in the media. TS often coexists with:

  • Learning disabilities
  • Autism spectrum disorder
  • Attention deficit hyperactivity disorder
  • Obsessive-compulsive disorder
  • Speech and language problems
  • Sleep problems
  • Depression or anxiety
  • Huntington’s disease
  • Creutzfeldt-Jakob disease

In these cases, the associated disorders and diseases are larger concerns than the tic disorder.

It is not known what causes tic disorders. There appears to be a genetic element. They are more common in males than females. Treatment may include:

  • Medications such as anti-seizure drugs, antidepressants, Botox injections, and muscle relaxants
  • Therapy to learn to resist the urge; but although people can learn to control the tics, doing so continually can be exhausting
  • Counselling to learn to avoid stress and anxiety, and deal with the impacts of prejudice and bullying
  • Deep brain stimulation for tics that don’t respond to other treatments and that impact a person’s quality of life

Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) interferes with a person’s ability to sustain attention, focus on a task, or control impulsive behaviour.

Research shows ADHD can be caused by a combination of things, including:

  • Brain function. A lower level of activity in parts of the brain that control attention and activity level.
  • Brain injury. Significant head injuries may cause ADHD in some cases.
  • Genes and heredity. A child with ADHD has a 1 in 4 chance of having a parent with ADHD. Another family member, such as a sibling, might also have ADHD. 
  • Premature birth. Early delivery increases the risk of developing ADHD.
  • Prenatal exposures. Drinking alcohol to excess or inhaling nicotine from smoking can increase the risk of developing ADHD.
  • Environmental toxins. In very rare cases, toxins in the environment, such as lead, can cause ADHD.

ADHD symptoms tend to differ for males and females. Males usually show externalized symptoms such as running, impulsivity, and physical aggression. Girls are more likely to be inattentive, have low self-esteem, and be verbally aggressive.

Growing public awareness means that many children who were not diagnosed 20 to 50 years ago are now adults seeking evaluation and treatment. People with ADHD may:

  • Fail to pay close attention to details
  • Make careless mistakes at work
  • Fidget with their hands or feet or squirm in their seat
  • Have trouble sustaining attention in tasks or fun activities
  • Leave their seat in situations where staying seated is expected
  • Not seem to listen when spoken to directly
  • Feel restless
  • Not follow through on instructions and fail to finish work
  • Have trouble organizing tasks and activities
  • Avoid, dislike, or be reluctant to do work that requires sustained mental effort

A person who shows 6 or more of these symptoms for at least 6 months, to a degree that is chronic and inconsistent with that person’s level of development, may receive a diagnosis of ADHD.

There are also positive attributes associated with ADHD. The Learning Disabilities Association of Alberta says that often people with ADHD:

  • Are very creative
  • Show strong leadership skills
  • Are compassionate and empathetic
  • Relate well to younger children, elderly people, and marginalized groups
  • Are at times able to hyperfocus and stick to a task
  • Are intuitive and perceptive
  • Have a powerful drive to move ahead

Barriers and challenges

Each person with a physical disability or neurological disorder or disease experiences life differently. But many will face financial, environmental, social, systemic, and personal challenges.

Some of these people may have adjusted to physically impairing diseases or injuries. Others may be dealing with grief, anger, denial, identity issues, and other reactions to loss and transition. They may also have low self-esteem, little self-confidence, and communication problems related to their disabilities.

In cases of sudden injury or traumatic disability, clients may not be able to continue in the same job they held before. They may need to return to the exploratory stage of career development. They may also need help to deal with grief and loss.

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