There are over 12 million people living with a neurological condition in England alone (ELTP 2019). NHS England (2022) defines these as any condition that affects the brain, spinal cord or nervous system. There are over 600 types, broadly categorised into:

  • Sudden onset conditions (e.g. acquired brain injury or spinal cord injury)
  • Intermittent and unpredictable conditions (e.g. epilepsy, ME, certain types of headache, or the early stages of multiple sclerosis)
  • Progressive conditions (e.g. motor neurone disease, Parkinson’s disease, or later stages of multiple sclerosis)
  • Stable neurological conditions (e.g. post-polio syndrome, or cerebral palsy in adults)

Disorders present with different symptoms, ranging from physical limitations to sensory and/or cognitive difficulties. Whilst each individual experience will be different, there will likely be some level of impact on their functional ability and occupational engagement/participation. For some (e.g., with migraine) this may be temporary until the next episode, for others it may be variable (e.g., Parkinson’s disease where function can vary over the period of a few hours), whereas someone who has had a neurological trauma, their function may be changed permanently.

Occupational therapists understand the relationship between the person, their environment, and how this relationship impacts on occupational engagement. Being aware of the individual’s requirements both physically and emotionally is essential to ensure both their short and long-term needs are met. When it comes to accessing bathroom activities, be that personal care, caring for others, or simply relaxing, bathroom alterations can often be the best way to meet the person’s needs. Bathroom redesign should be based on a wide range of factors such as the likely prognosis, the client’s wishes, the client’s norms as well as budgetary restraints. Identifying the best solution where there is such diversity in terms of diagnosis, symptoms and prognosis is challenging; however, fundamental to any adaptation is being person centred. So, understanding their physical, cognitive, sensory, and emotional deficits alongside their abilities, and relating that to what is meaningful to them is key. Where there are physical deficits, common challenges are:

  • Accessing bathroom because it is upstairs
  • Bathroom not big enough (if wheelchair dependant for example)
  • Transferring in and out of bath
  • Transferring onto toilet
  • Cleaning self after using the toilet

Person in wheelchair using grab rails to aid use of toilet.

Where there are cognitive and sensory impairments, other considerations may need to be considered. For example, where there is a sensory deficit that impacts on recognising hot/cold water, a temperature regulator may be required, or where memory is affected, e.g., leaving taps running, a smart device may be needed to prompt the person. In addition, we must also consider other household members who are also using that space.

For conditions that will deteriorate, future proofing is imperative, as this will be not just more cost effective, but reduces the upheaval that is associated with housing adaptations. As each individual will respond differently, taking a holistic approach is crucial, for example, whilst we may know the likely prognosis, they may yet to come to terms with this and so being sensitive to this is important. So, discussing removal of the bath for a level access shower and replacing the toilet for a wash/dry alternative, because this is what you know they will likely need in the future, may not be appropriate at that time. Making a judgement about how to sensitively discuss bathroom adaptations is a skill that if timed wrongly can have a negative impact on the therapeutic relationship.

In summary, bathroom design will depend on several factors:

What is the person’s goal?E.g., independence with bathing / showering / toileting.
What is their diagnosis / prognosis?How is this impacting / will this impact on their goal?
How is the person managing their diagnosis (physically and emotionally)?What approach might you take in discissing bathroom design with them?
What are the current obstacles?E.g., person cannot safely transfer into bath because of their diagnosis.

Person lacks ability to wipe after using toilet.
Are there any other factors to consider?E.g., Other household members.

Can the design be future proofed?
What is the most approptiate solution to achieve the client goal?Remove bath and replace with level access shower

Replace toilet with wash / dry alternative

Keeping the person at the centre throughout will help identify the best solution and is crucial to maintaining a positive relationship.

Elective Care Transformation Programme (2019) Transforming elective care services: Neurology
NHS England (2022)