9
Education and Training in Rehabilitation Science and Engineering

This chapter examines education and training as it prepares scientists and engineers to contribute to rehabilitation science and engineering and the status of current support and opportunities for such education and training. The chapter first outlines the committee's findings regarding the present status and need for the organization of a more widely recognized field of study, but not a new profession, of rehabilitation science and engineering. This is followed by a summary of the major sources of federal support for training in rehabilitation and opportunities in training and education among the practices and disciplines of rehabilitation. Finally, based on an analysis of the current status and needs, the committee presents several recommendations that are designed to encourage interdisciplinary education and training, and expanded capacity in the field.

The Field of Rehabilitation Science and Engineering

As a part of its task, the committee considered the status and needs for education and training related to research in rehabilitation science and engineering,* and the potential need for a new discipline.

*  

As defined in Chapter 1, the committee uses the term rehabilitation science and engineering to emphasize the importance of both science and engineering in advancing rehabilitation efforts and addressing the needs of people with disabling conditions.



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--> 9 Education and Training in Rehabilitation Science and Engineering This chapter examines education and training as it prepares scientists and engineers to contribute to rehabilitation science and engineering and the status of current support and opportunities for such education and training. The chapter first outlines the committee's findings regarding the present status and need for the organization of a more widely recognized field of study, but not a new profession, of rehabilitation science and engineering. This is followed by a summary of the major sources of federal support for training in rehabilitation and opportunities in training and education among the practices and disciplines of rehabilitation. Finally, based on an analysis of the current status and needs, the committee presents several recommendations that are designed to encourage interdisciplinary education and training, and expanded capacity in the field. The Field of Rehabilitation Science and Engineering As a part of its task, the committee considered the status and needs for education and training related to research in rehabilitation science and engineering,* and the potential need for a new discipline. *   As defined in Chapter 1, the committee uses the term rehabilitation science and engineering to emphasize the importance of both science and engineering in advancing rehabilitation efforts and addressing the needs of people with disabling conditions.

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--> In doing this, the committee considered historical examples and rationale for the establishment and growth of other fields. It also considered the differences between academic and scientific fields of study and professional disciplines. Assessing the Field In analyzing the current state of knowledge and education related to rehabilitation science and engineering, the committee came to three initial observations. First, rehabilitation-related research is conducted within a variety of disciplines, and although this research is integral to each discipline, it is not dominant. Second, each of the separate existing disciplines has complementary and distinct perspectives on disability and rehabilitation, yet all address the enabling-disabling process as a fundamental concept. The third observation is that the research in the separate health, health professional, and engineering disciplines, although complementary, is not optimally interfaced or balanced. A distinct field of study—one that would contribute to other disciplines but that gives a conceptual structure across disciplines—could be beneficial if it enhances the current research, stimulates innovations, and coordinates the growth of knowledge. The following sections discuss each of these three findings. Rehabilitation-Related Research in Existing Disciplines The committee found that the existing health professional disciplines generate and use rehabilitation-related knowledge as the basis for preparing practitioners and delivering services. Many health professional disciplines participate in generating knowledge relevant to rehabilitation and the prevention of disability in the presence of disabling conditions. The most prolific and productive professional discipline in this regard is medicine and its subrealm of physical medicine and rehabilitation. Physical medicine and rehabilitation has also successfully coordinated with engineering in generating new knowledge and clinical therapeutic devices. Rehabilitation-related research is conducted from the perspectives of the disciplines of nursing (rehabilitation nursing), physical therapy, occupational therapy, and other health care professions. In each case, the professional disciplines all conduct research that contributes not only to their profession but also to the field of rehabilitation science and engineering. In each of these disciplines, however, rehabilitation-related research represents only a subset of knowledge and activity. Other areas of research are often more dominant in these disciplines, such as those related to acute illnesses, primary prevention of acute illnesses, health promotion, pro-

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--> fessional issues, or ethical issues related to health care. Thus, rehabilitation-related research, although integral to each discipline, is not dominant. Multiple Perspectives on a Common Goal The committee's second observation about the state of rehabilitation-related research was that each of the separate health professional, basic science, and engineering disciplines has complementary yet distinct perspectives on disability and rehabilitation reflecting the practical aims of the discipline. Medicine, for example, has pioneered the application of biological, medical, and engineering sciences in the elucidation of the pathological and pathophysiological bases of disabling conditions. The therapies developed by medicine are directed primarily toward preventing, treating, or ameliorating disease and the manifestations of disease that underlie disabling conditions. Medicine has developed innovative and effective therapies for reversing or compensating for losses in human functional capacity as a result of disabling conditions and disease. Medical therapies usually involve interventions directed toward the individual person. This success of medicine has been accomplished in part by the joining of forces of medical scientists with engineering scientists to develop assistive devices that replace body structures (e.g., artificial limbs), replace normal organ function (e.g., cardiac pacemaker), create changes in the physical environment to allow for independent living (e.g., smart environments), and prevent secondary conditions (e.g., pressure-controlled seats). Engineering science has focused primarily on manipulation of the physical environment and development of assistive devices for use by medicine. Physical therapy emphasizes preservation and recovery of joint and muscle function for performing tasks related to independent living. Occupational therapy emphasizes a client-centered approach to help individuals gain skills and modify environments so that individuals with disabling conditions can perform the tasks and activities of self-maintenance and work. Nursing interventions are intended to promote health and optimize performance of activities of daily living, an independent and autonomous lifestyle, and achievement of overall comfort and well-being, despite the continued presence of disease and functional limitations. Public health adds yet another perspective in developing the methods and knowledge to view disability and rehabilitation from a population perspective as opposed to the individual person- and person-environment-based foci of the preceding examples. Public health also offers knowledge for evaluating the cost-effectiveness of care and health pro-

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--> motion at the population level. Thus, the knowledge generated through public health research is important to changing the attitudinal and general societal views of disability and to changing health care policy. The other health-related disciplines (speech-language pathology, audiology, recreation, etc.) have similar distinct perspectives and research emphasis areas that are important to providing an understanding of disability and rehabilitation. In each of these examples, it is evident that respective disciplines are investigating the same subject: the enabling-disabling process. The health professional disciplines and engineering are the primary sites for the integration of knowledge from the basic sciences (the physical, biological, social, and behavioral sciences) into conceptualizations that result in effective and innovative clinical interventions that constitute the basis of the enabling process. As explained in Chapter 3, this process encompasses (1) minimization of environmental barriers to independent functioning and (2) maximization of autonomous, independent functioning of the person in the face of a disabling condition(s). Because of this, the breadth of perspectives is essential in addressing the concerns of consumers and society. Some consumers request that disability be "demedicalized" by focusing on altering the social and physical environments for people with disabling conditions. Some consumers want to be cured. Society in general expresses a concern for the use of cost-effective strategies including prevention and reversal of functional limitations of people with disabling conditions. Each discipline, then, contributes to the process that addresses these multiple requests, concerns, and mandates. Although each discipline approaches the enabling-disabling process from its own area of expertise, ultimately they unite in the common goal of promoting health and preventing disease and disability in people with disabling conditions. This is the essence of rehabilitation science and engineering and a major reason that academic and scientific structure needs to organize the field of rehabilitation science and engineering. Integrating the Multiple Perspectives The third major finding of the committee is that the research in the separate health, health professional, and engineering disciplines, although complementary, is not optimally interfaced or balanced. This is especially noteworthy given that people with disabling conditions are demanding access to changes and interventions that range from reversal of the pathology (i.e., cure) to removal of all environmental constraints and barriers without altering the person with the disabling condition. There is a clear consumer mandate for options allowing personal choice and a pro-

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--> vider mandate for cost-effective approaches. These mandates challenge the disciplines to build a balanced, coordinated, and broad scope of research. Research and core knowledge of this scope and balance are unlikely to emanate from the separate health, basic science, and engineering disciplines now conducting rehabilitation-related research without a mechanism to view each discipline's contribution within the context of an organizing situation, such as that offered by a field of study. As mentioned above, a wide range of health care professionals is necessary to address the needs of people with disabling conditions and to prevent primary and secondary disabling conditions. Furthermore, changes in the health care delivery system show trends toward the greater use of primary care providers (including physicians, therapists, and nurse practitioners), multidisciplinary professional health care teams, and case management of clients by nonphysicians and diminished access to specialists. These forces do not call for a new type of rehabilitation clinician or practitioner; the roles and licensure of existing health care providers are established and complementary. There is, however, a growing need for better integration of the health care disciplines in the rehabilitative processes. This requires a common knowledge base upon which other disciplines can build. The committee sees an increased need for rehabilitation-related education in and across all existing health care professions so that knowledge pertaining to rehabilitation science and engineering can be integrated into the knowledge base of all general and primary care providers. Assessing the Need for a New Discipline The number and nature of disciplines have changed over time with the emergence of new disciplines, the merging of existing disciplines, and the loss of disciplines due to obsolescence of the knowledge (Flint, 1975). The committee explored the need for a new discipline of rehabilitation science and engineering with the understanding that new disciplines often are recognized as fields of study until their structure is well-established and organized. The process of organizing a new field of study usually stimulates the increased and coordinated generation of knowledge by scholars and researchers. This developmental perspective of the creation of new scientific disciplines guided the committee's evaluation, conclusions, and recommendations regarding the need for academic and scientific structure in the field of rehabilitation science and engineering. The Nature of a Discipline The nature of academic and scientific disciplines is to coordinate, emphasize the importance of, and stimulate research. By having a con-

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--> ceptual structure, disciplines provide an opportunity to coalesce the knowledge in a given field. Anthropology is an example from more than a century ago (Flint, 1975). A more contemporary example is the neurosciences, although this is more correctly considered to be an affinity group by most in the field. In both cases, however, the new science overlapped parts of the disciplinary matrix of existing disciplines; this did not necessitate removal of content or research from any existing disciplines. Rehabilitation science and engineering is and should continue to be a part of the research in each of the contributing scientific, professional, and engineering disciplines. The existence of separate health professional and engineering disciplines represents an opportunity to generate and integrate knowledge for practice and to prepare the appropriate mix and numbers of health care team members knowledgeable in rehabilitation science and engineering for the emerging managed health care system. Still, it is necessary to understand the nature of the field as proposed here. Rehabilitation science and engineering is a scientific and academic field of study—but not a professional discipline—whose purpose is to generate new knowledge for use by professionals and consumers. Although rehabilitation science and engineering is not yet at a stage where it could call itself a discipline, the committee believes it to be an emerging field of study that could evolve into a discipline. Scientific Disciplines Disciplinary syntax, that is, the methods and criteria for the acceptance of knowledge (Schwab, 1964), is the basis for distinguishing the sciences from the arts and humanities. Scientific disciplines use rigorous, objective methods and criteria to determine acceptable knowledge because they embody knowledge that is generalizable, predictable, and in the form of general laws describing the nature or behavior of events or phenomena. The sciences share a common assumption that some degree of predictability and order exists in the phenomena that make up the world and the universe (Flint, 1975). Empiricism, as a philosophy of science, uses the syntax of the rehabilitation-related scientific disciplines. Empiricism has evolved over time and was significantly changed into its modem form by Thomas Kuhn (1962). Kuhn characterized science as problem solving (Kuhn, 1979) rather than the means to absolute truth and emphasized the importance of prevailing paradigms, or world views, and revolutionary changes in paradigms (Kuhn, 1962). Contemporary empiricism requires deductive reasoning, objectivity, theoretical models, and substantiation of theoretical claims by observable or detectable and measurable phenomena (Cronbach and Snow, 1977; Serlin, 1987). The committee considers rehabilitation science and engineering to be a field of study that fits well in the context of the existing scientific disciplines and within the context of contemporary empiricism.

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--> Academic Versus Professional Disciplines Disciplines that are purely academic differ from those with a professional component (Donaldson and Crowley, 1978). Disciplines in both categories are sciences by virtue of their syntax. The distinction between academic and professional disciplines has to do with the intended use of the knowledge and the resultant requirements for the disciplinary theoretical matrix. The primary aim of an academic discipline is to elucidate and understand phenomena. Basic research in the academic disciplines is discovery for discovery's sake, and applied research is discovery of the applicability (i.e., real-world practicality) of the knowledge. In contrast, the professional disciplines (e.g., medicine, nursing, speech-language pathology, audiology, and occupational and physical therapy) have practical aims and generate knowledge to serve as the basis for service delivery. Professional disciplines discover how to use knowledge in the real world. The professional disciplines deal with the actual implementation of knowledge in a practical sense (Donaldson and Crowley, 1978). Prescriptive theories are thus the scientific basis for the clinical therapeutic interventions used by health care professionals. Academic disciplines have educators and research scholars, whereas professional disciplines alone additionally have practitioners who use the knowledge to provide service and to influence the use of societal resources and implementation of policies addressing professional issues (Donaldson and Crowley, 1978). The academic versus professional disciplinary status of rehabilitation science and engineering was an important consideration for the committee. Ultimately, it was agreed that rehabilitation science and engineering should not be developed into a new professional discipline—neither is it an academic or scientific discipline. Rehabilitation science and engineering is, however, emerging as an organized, multidisciplinary field of study and as such makes unique contributions to the health, productivity, and quality of life of people with disabilities. Rehabilitation science and engineering also has the capacity to evolve into an academic and scientific discipline that will further enhance the growth (scope and balance) of knowledge and allow for a new perspective of rehabilitation, perhaps transcending and crosscutting the perspectives of the existing basic and applied sciences and professional disciplines. Defining the Field of Rehabilitation Science and Engineering The findings presented above led the committee to conclude that the organization of rehabilitation science and engineering as a field of study is key to stimulating innovations and coordinating the growth of knowledge emanating from rehabilitation-related research. The field is ripe for major advances through coordinated research efforts and the field's broad

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--> perspective of rehabilitation, engineering, and disabling conditions. Expanding research in the field is likely to provide the knowledge to respond to the needs of consumers with disabling conditions, health care providers, and policy makers. The developing field of rehabilitation science and engineering needs to be responsive to all of these mandates. The Purpose of Rehabilitation Science and Engineering Organizing rehabilitation science and engineering as a defined field of study that is more widely accepted as such should help generate new knowledge for use by professionals and consumers. As a science, rehabilitation science and engineering would crosscut and share with, rather than subsume or replace, research emphases in the existing health and engineering disciplines. This field would also identify and address gaps in knowledge and provide direction for multiperspective research and service unlikely to be accomplished within the separate, single-perspective health and engineering disciplines. Rehabilitation science and engineering could offer its own doctorate or provide a graduate minor curriculum for doctoral students in other programs. The knowledge generated within the field of rehabilitation science and engineering can be used as a basis for practice by all health care professionals and can serve to train researchers in separate disciplines. Thus, a physician, nurse, physical therapist, occupational therapist, public health officer, basic scientist, or engineer might receive a part of his or her research training in rehabilitation science and engineering; this could be as a predoctoral or postdoctoral fellow. Rehabilitation science and engineering will create organizational units that can also serve as centers of excellence and training to expand the resources and services of the existing rehabilitation-related disciplines. The knowledge generated from the science should provide information to guide service delivery, support policy development, and propose strategies that will improve the lives of people with disabling conditions and their families. Developing Paradigms in Rehabilitation Science and Engineering As an emerging field of study, rehabilitation science and engineering operates under few accepted paradigms. Paradigms, defined as ''universal achievements that for a time provide model problems and solutions to a community of practitioners," guide research and unite the ideas and terminology of a scientific field (Kuhn, 1962). The absence of paradigms in rehabilitation science and engineering should not be looked upon negatively; it is a state that all sciences pass through. When this is the case, however, agreement on the direction of action is difficult. Kuhn says, "In

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--> the absence of a paradigm or some candidate for paradigm, all of the facts that could possibly pertain to the development of a given science are likely to seem equally relevant" (Kuhn, 1962). Without paradigms, fact gathering tends to be random and to lack direction, and one practitioner's ideas are as valid as any other's. Kuhn suggests that when this is the case, practitioners write books to present their own views and that the material is often directed as much toward other schools of thought (or other practitioners) as toward the topic under consideration. Is it practical to think that some aspects of rehabilitation can become a mature science? The process requires placing stronger emphasis on empirical knowledge through experimentation, case studies, and information gathering to learn how to best address the problems faced by people with disabling conditions. Ultimately, a global paradigm for rehabilitation science and engineering may never develop, but smaller areas, such as locomotion science, movement science, occupational science, nursing science, and others, may supplement developing or mature sciences that are already connected with the rehabilitation field (e.g., neurosciences, brain science, and medical science). In addition, the contributions made by the development of rehabilitation science and engineering will lead to more evidence-based practice in the clinical disciplines and which should result in more effective services for people with disabling conditions. Summary Rehabilitation science and engineering, defined in this report as encompassing basic and applied aspects of biology, medicine, and engineering as they relate to restoring human functional capacity and improving a person's interactions with the surrounding environment, is beginning to emerge as an organized, multidisciplinary field of study. As a field, rehabilitation science and engineering focuses on multidisciplinary research and provides a common knowledge base for individuals working on a rehabilitation team. Because the committee has determined that rehabilitation science and engineering is an evolving scientific and academic field of study, and that current professional fields will remain, the important issue in education and training becomes how to train researchers in an increasingly interdisciplinary field and how to educate professionals in the common knowledge of the many disciplines that make up the field of rehabilitation. Currently, many mechanisms exist for the purposes of providing training and education in rehabilitation science and engineering. The following section examines those mechanisms to illustrate the breadth of both the present opportunities and the needs in the field. The final section of this chapter outlines some general approaches

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--> that will encourage the development of the field of study rehabilitation science and engineering and the interdisciplinary use of new knowledge. Support for Education and Research Training in Rehabilitation Science and Engineering Support for education specific to rehabilitation science and engineering is substantial in many respects. However, it is difficult to determine accurately the extent and nature of this support. Part of the difficulty is due to the various perceptions and definitions of rehabilitation and what actually constitutes rehabilitation research. In some instances it is evident that the activities supported by programs are within the mainstream of rehabilitation with respect to education, training, and research, but the relative priorities and commitments among these areas are not always evident. National Institute on Disability and Rehabilitation Research The National Institute on Disability and Rehabilitation Research (NIDRR) is part of the Office of Special Education and Rehabilitative Services of the U.S. Department of Education. NIDRR's mission is to contribute to the independence of people with disabling conditions. NIDRR accomplishes this mission by funding research, demonstration projects, training, and other related activities to maximize the full inclusion and integration of people with disabling conditions into society. Through grants, contracts, and cooperative agreements, NIDRR funds research designed to improve systems, products, and practices in the rehabilitation field. NIDRR is also charged with ensuring the widespread distribution of practical scientific and technological information in usable formats. The research funded by NIDRR covers all aspects of disability, including brain injury, spinal cord injury, multiple sclerosis, and back pain, and broader areas, such as technology, accessibility, aging, service delivery, policy, ethics, recreation, and community integration. These programs are described in detail in Appendix B. The exact nature of the education and training varies from project to project. In most instances project activities include the development of curricula and the presentation of training seminars. The target audiences are health and rehabilitation providers and people with disabling conditions. The educational and training activities carried out through these programs vary widely with respect to field, scope, content, audience,

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--> duration, medium, and other considerations. Education and training are targeted to health and rehabilitation professionals, individuals with disabling conditions and their families, students preparing for rehabilitation research careers, selected segments of the general public, and prospective employers of individuals with disabling conditions. The areas of training and education supported range from science and engineering design activities over an extensive range of applications to behavioral studies and social applications. The formulation and delivery of education and training to these audiences also vary considerably and include both informal and highly structured approaches and methods. The content areas supported by NIDRR projects reflect the widest spectrum that may be inferred in the scope of rehabilitation science and engineering. However, NIDRR supports two programs designed to train disability researchers. Research Training Grants The purpose of the NIDRR research training grants is to expand the capability in the field of rehabilitation research by supporting projects that provide advanced training in rehabilitation research. These projects provide research training and experience at an advanced level to individuals with doctoral or similar advanced degrees who have clinical or other relevant experience, including experience in the management of basic science research in fields pertinent to rehabilitation, to qualify those individuals to conduct independent research on problems related to disability and rehabilitation. Fellowships Fellowships, named for the late Mary E. Switzer, build future research capacity. NIDRR makes awards on two levels: Distinguished fellowships go to individuals of doctorate or comparable academic status who have had 7 or more years of experience relevant to rehabilitation research. Merit fellowships are given to people in earlier stages of their research careers. National Center for Medical Rehabilitation Research The National Center for Medical Rehabilitation Research (NCMRR) was established within the National Institutes of Health (NIH) by legislation passed in 1990. The center is a component of the National Institute of Child Health and Human Development. The mission of NCMRR is to foster development of the scientific knowledge needed to enhance the health, productivity, independence, and quality of life of people with

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--> als from other fields is increasing. EIS includes doctoral-level epidemiologists, statisticians, and nurses. CDC also offers a Postdoctoral Research Associates Program, a Visiting Scientist Program, Visiting Associate Program, and a Guest Researcher Program. U.S. Department of Veterans Affairs Research and development in the U.S. Department of Veterans Affairs (VA) advances the diagnosis and treatment of health problems prevalent among patients who are veterans by applying findings of VA medical research studies throughout the hospital system. The scope of the VA-funded research portfolio extends from basic laboratory research on the cause, treatment, and cure of a variety of diseases and disorders to fundamental clinical research on patient care and management. There is emphasis on diseases and disorders affecting veterans, but the results are applicable to the health care of all Americans. VA is not a granting agency, but rather funds an intramural program for investigators at VA medical centers. The VA program encompasses three areas of research and development: medical research, health services research and development, and rehabilitation. The VA rehabilitation research and development program integrates the multiple disciplines of science, engineering, and medicine to investigate and develop concepts, processes, and products that directly meet the special needs of veterans with disabling conditions. Scientific investigation is carried out in areas of physical orientation, mobility, and manual skills enhancement, spinal cord injury; prosthetics, amputation management, and orthotics, communication; cognition; auditory and visual sensory aids; vocational placement; and recreational opportunity. Priority emphasis is given to those investigator-initiated studies whose results benefit veterans with war-related injuries. Current special emphasis areas are orthopedics: prosthetics, orthotics, and amputation management; neurology: spinal cord injury, traumatic brain injury, and nerve injury; communications, cognition, and sensory aids: vision, audition, speech, and deglutition; and disabling conditions and conditions associated with aging: cardiorespiratory, metabolic, muscular, skeletal, and stability conditions. VA investigators are guided by letters of information stating the current foci within these priority areas. Internal letters of information

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--> are developed through strategic planning workshops with the participation of rehabilitation clinicians and researchers, as well as users of rehabilitation technology. VA currently operates four training and support programs, each targeting several different levels of investigators. Clinician investigators are trained either in the Medical Research Service or in the Health Services Research and Development Service Career Development Programs. Basic scientists are supported in Medical Research Service and Health Services Research Development Research Career Scientist Programs. VA recently completed a review of its research and training programs by the Research Realignment Advisory Committee (RRAC). This committee reviewed the restructuring of the VA system from a medical center-based system to a system based on integrated service networks, the current demographics of patients in VA medical centers, and the structure and function of the three VA research services (medical, health services, and rehabilitation), including the various training and career development programs associated with these research programs. In a review draft released June 26, 1996, RRAC recommended that the Rehabilitation Research Service and Development Service consider a career development program similar in structure and funding to those in the Medical Research Service and Health Services Research and Development Service Career Development Programs. This career development program would include clinician-scientist career development consisting of three levels of awards: an entry level and two higher levels corresponding to an assistant professor and a more senior investigator. The Research Career Scientist Program would provide support for the recruitment and retention of basic science investigators. Career scientist awardees would be expected to seek extramural salary support and would be reviewed annually. Annual reviews should encourage excellence in at least two of the following three areas: VA service on committees, organized activities that contribute to clinical interest and the intellectual climate at the local VA medical center, and mentoring, including coauthorship of papers and grants. Professional Rehabilitation Education and Training Each profession within the scope of rehabilitation science and engineering maintains its own credentialing system for practitioners and an accrediting body for professional education. The following is a brief overview of current educational and certification requirements for rehabilitation practitioners.

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--> Physical Medicine and Rehabilitation Physical medicine and rehabilitation, also referred to as rehabilitation medicine or physiatry, is the primary medical specialty concerned with evaluating, diagnosing, and treating patients with disabling conditions that involve the musculoskeletal, neurological, cardiovascular, or other body systems. There are physicians in the fields orthopedic surgery and neurology who have received rehabilitation training. The primary focus of rehabilitation medicine is on maximal restoration of physical, psychological, social, and vocational function and on evaluation of pain. For diagnosis and evaluation, a physician may include the techniques of electromyography and electrodiagnosis as supplements to the standard history and physical, X-ray, and laboratory examinations. In addition to traditional treatment modes, specialists in rehabilitation medicine may use therapeutic exercise, prosthetics, orthotics, and mechanical and electrical devices. Physiatrists are certified by the American Board of Physical Medicine and Rehabilitation through the administration of written and oral examinations that assess candidate performance in basic sciences and clinical aspects of rehabilitation practice. Upon approval of the application and the candidate's successful completion of the examinations, the board grants a certificate to the candidate. The recipient of the certificate is known as a certificant or a diplomate of the American Board of Physical Medicine and Rehabilitation. In addition, an application and examination process are being developed for certification of special qualifications in spinal cord injury medicine. The specialty of physical medicine and rehabilitation has 79 accredited residency programs. In 1994-1995 the training programs offered 1,313 residency positions, and 1,277 (97 percent) of these were filled. The board has given written and oral examinations annually since 1947 and has certified 4,940 physicians as diplomates; 2,562 of these have been certified in the past 10 years, with 298 certified in 1995. Rehabilitation Engineering Although the baccalaureate degree is most common in engineering practice, many engineers obtain master's degrees after they go into practice in order to specialize or to change career directions. Practicing biomedical engineers frequently have master's degrees. The doctorate has become more prevalent in engineering since the late 1950s and is still regarded as a research degree although that view has changed somewhat over the last few years as persons with doctoral degrees have become involved at decision-making levels related to development, implementation, or acquisition of new technologies. Engineering schools still empha-

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--> size practical application, uniting hand skills and intuitive knowledge with the precision of mathematics and the physical sciences. This blending of the practical and the theoretical was beneficial to good, practical engineering. Sometimes this creative kind of union of the practical and theoretical appears in individual persons, and sometimes it comes about mainly through design teams. Future rehabilitation engineers who provide service to clients probably will need either education at least to the master's level in engineering, dual education in engineering and in a rehabilitation specialty (e.g., Physical Therapy, Occupational Therapy, Prosthetics or Orthotics, etc.), or specialized advanced degrees in rehabilitation science and engineering. Research in rehabilitation engineering will be led largely by engineering doctorates, doctorates dually educated in engineering and in rehabilitation (e.g., Physical Medicine and Rehabilitation or Occupational Therapy), or those with advanced degrees in rehabilitation science. Education programs will also need to have counterpart programs that foster the development of technical personnel in the rehabilitation field. Much of the practical day-to-day aspects of rehabilitation technology can be sustained by highly skilled people with appropriate technical backgrounds. Rehabilitation Nursing Professional schools of nursing prepare nurses for general practice in a variety of settings including the community. Graduates receive a baccalaureate degree from colleges or universities whose nursing program(s) is accredited by the National League for Nursing (NLN). Advanced practice nurses (clinical specialists, nurse practitioners) complete requirements for a master's degree in a given clinical area such as rehabilitation nursing (accredited by NLN). Doctoral nursing programs prepare nurses in theory and research to increase the body of nursing knowledge and practice. In addition to the academic requirements for the levels of nursing practice, nurses may sit for a certification exam in rehabilitation. The Certified Rehabilitation Registered Nurse (CRRN) certification program was developed by the Association of Rehabilitation Nurses and is directed and implemented by the Rehabilitation Nursing Certification Board. The CRRN certification program has grown every year since its inception in 1984, and more than 12,400 rehabilitation nurses hold the CRRN credential. The goals of the CRRN program are to promote expertise in rehabilitation nursing, provide a standard for recognizing qualifications, and validate specialized knowledge to enhance the care of people affected by disabling conditions and chronic illness. Registered nurses with a minimum of 2 years of work experience as a registered profes-

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--> sional nurse in rehabilitation nursing within the previous 5 years are eligible to take the examination. The certification is valid for 5 years. Renewal or certification may be obtained by reexamination or by achieving points of credit through a combination of continuing education, formal course work, professional publication, presentations, or submission of test items for the CRRN examination. Assistive Technology Rehabilitation Engineering and Assistive Technology of North America (RESNA) administers a credentialing program for rehabilitation professionals involved in assistive technology or rehabilitation engineering service delivery. Individuals with degrees in rehabilitation science who, in addition, have work experience related to assistive technology are eligible to take the credentialing examination. A rehabilitation science degree is defined as a degree in one of the following: occupational therapy, physical therapy, speech or language pathology, special education, medical doctor, nursing, rehabilitation counseling, orthotics, or prosthetics. RESNA offers two credentials: assistive technology practitioner, for service providers most frequently involved in a assessment of a consumer's need or training in the use of a particular device, and assistive technology supplier, for service providers most frequently involved in the sale and service of assistive technology devices. Requirements for credentialing are a combination of education, field of study, and work experience specific to client service in the area of assistive technology. RESNA's Rehabilitation Engineering Professional Specialty Group is in the process of developing the requirements for a rehabilitation engineer credential. Rehabilitation Counseling The Council on Rehabilitation Education (CORE) is a not-for-profit corporation that is the accrediting body for master's degree programs in rehabilitation counselor education. The purpose of CORE accreditation of rehabilitation counselor education programs is to promote the effective delivery of rehabilitation services to individuals with disabling conditions by promoting and fostering continuing review and improvement of master's degree-level rehabilitation counselor education programs. Another goal is to meet the personnel needs of both public and private rehabilitation agencies by providing graduates who have the skills, knowledge, and attitudes necessary to provide rehabilitation counselor services to individuals with physical, mental, or emotional needs. There are 84 accredited master's degree programs in rehabilitation counselor education.

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--> Physical Therapy Physical therapy exams, treats, and instructs individuals in methods to correct, alleviate, and limit physical disability. Physical therapy, which is the care and services provided by or under the direction of a physical therapist, includes the following activities: Examining and evaluating individuals with impairment, functional limitation, and disability or other health-related conditions to determine a diagnosis, prognosis, and intervention. The tests and measures used may include assessment of functional capabilities in self-care and home management and in work, community, and leisure activities; balance and locomotion abilities; musculoskeletal, neuromuscular, cardiopulmonary, and integumentary systems; sensory and neurophysiologic functions (e.g., by electromyographic and motor nerve conduction testing); pain; need for and use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices; and environmental barriers. Alleviating impairment, functional limitation, and disability by designating, implementing and modifying therapeutic interventions that may include patient-related instruction; therapeutic exercise; functional training in self-care and home management and in community, work,and leisure activities (including activities of daily living, instrumental activities of daily living, work hardening, and work conditioning); manual therapy techniques (including mobilization and manipulation); prescription, application, and, as appropriate, fabrication of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment; airway clearance techniques; wound management; and electrotherapeutic, physical, and mechanical modalities; Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in all age populations. Engaging in consultation, education, and research. As of October 1996, the United States had 155 accredited physical therapy programs (48 at the bachelor's level, 102 at the master's level, 2 at the doctor of physical therapy level, and 195 accredited physical therapy assistant programs. The Commission on Accreditation in Physical Therapy Education of APTA determines the accreditation status of education programs for the physical therapist and physical therapist assistant. To meet the increasing need for qualified faculty, APTA recently initiated a program to support doctoral education for qualified physical therapists. According to APTA, the United States has an estimated 97,000 licensed physical therapists. Of this number, 74 percent (71,780) practice

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--> full time, 19 percent (18,430) practice part time, and 7 percent (6,790) are not practicing or are retired. Thus, the current supply of physical therapists is estimated to be 90,210. Occupational Therapy Occupational therapy uses selected tasks and activities to restore, reinforce, and enhance performance in people with disabling conditions by facilitating learning of those skills and functions essential to help an individual adapt and achieve the capacity to perform with satisfaction to self and others those tasks and roles essential to productive living and to the mastery of self and the environment. Occupational therapy serves a diverse population in a variety of settings such as hospitals and clinics, rehabilitation facilities, long-term care facilities, extended care facilities, industry sheltered workshops, schools and camps, private homes, and community agencies. Occupational therapists both receive from and make referrals to appropriate health, educational, or medical specialists. The National Board for Certification in Occupational Therapy is the credentialing organization for occupational therapists. To become a registered occupational therapist, an individual must (1) be a graduate of an accredited occupational therapist education program and have successfully completed all therapist-level field work required by the education programs (but not less than 6 months) and (2) have successfully completed the certification examination for registered occupational therapist. There are currently 71,335 registered occupational therapists in the United States, and of these, the estimated workforce is 47,785 (Health Policy Alternatives, Inc. 1996). The Accreditation Council for Occupational Therapy Education of the American Occupational Therapy Association accredits programs for occupational therapists. The council establishes, maintains, and promotes appropriate standards of quality for educational programs in occupational therapy and provides recognition for educational programs that meet or exceed the minimum standards. The standards are used for the development, evaluation, and self-analysis of baccalaureate and postbaccalaureate entry-level professional occupational therapy programs. Orthotics and Prosthetics An orthotist provides care to patients with congenital or traumatic disabling conditions of the musculoskeletal structure of the body by evaluating, designing, fabricating, fitting, and aligning braces knows an orthoses. A prosthetist provides care to patients with a partial or total

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--> absence of a limb by evaluating, designing, fabricating, fitting, and aligning those artificial limbs known as prostheses. There are currently 3,000 certified orthotists, prosthetists, and prosthetist-orthotists in the United States. Education programs are accredited by the National Commission on Orthotic and Prosthetic Education. The American Board for Certification in Orthotics and Prosthetics, Inc. (ABC), is a credentialing body established by the orthotic and prosthetic professions to identify those practitioners who have satisfied the minimum qualifications to render public health services in these disciplines. ABC conducts examinations to test the competencies of those individuals engaged in or intending to be engaged in the practice of orthotics or prosthetics who voluntarily apply for the examination process. Three examinations are required: written, clinical patient management, and written simulation examinations. Examination content assesses performance in five domains: clinical assessment, patient management, technical implementation, practice management, and professional responsibility. Audiology and Speech Pathology The American Speech-Language-Hearing Association issues certificates of clinical competence to individuals who present evidence of their ability to provide independent clinical services to people who have disorders of communication. Individuals who meet the standards specified by the association's Council on Professional Standards may be awarded a certificate of clinical competence in speech-language pathology or a certificate of clinical competence in audiology. Individuals who meet the standards in both professional areas may be awarded both certificates. The American Speech-Language-Hearing Association represents 87,060 members and nonmember certificate holders. There are currently 11,211 certified audiologists and 69,334 certified speech-language pathologists in the United States. Individuals holding dual certifications totaled 1,413 in 1996, which represents a decrease for the second consecutive year. More than one-third of audiologists are employed in a private practice setting, whereas 25 percent of speech-language pathologists are employed in such settings. More than 50 percent of speech-language pathologists are employed in a school setting and 39 percent are employed in a health care facility. Audiologists are generally employed in health care facilities (72 percent): 47 percent in nonresidential health care facilities such as physician or audiologist offices, 23 percent in hospitals, and 4 percent in residential health care facilities. The majority of speech-language pathologists (82 percent) and audiologists (80 percent) reported their primary employment function as clinical service provider.

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--> Academic Rehabilitation Education Programs The committee recommends interdisciplinary training in rehabilitation science and engineering and encourages the development of academic programs that promote research training for clinicians. Building a rehabilitation science requires highly trained professionals who can develop a knowledge base that can be disseminated to consumers of research and used to promote evidence-based rehabilitation practices. Foremost is the need for clinical trials of therapeutic interventions that rely less on clinical experience and more on systematic investigation by using standardized outcomes measures. Support for rehabilitation science and engineering should be concentrated in environments that recognize and emphasize the interdependence of research, clinical service, education, and training. Education and training in rehabilitation science should also recognize and address the interdependence of professional disciplines serving the field of rehabilitation. Examples of Existing Programs Examples of such integrated academic programs include the master of arts in disability and rehabilitation currently offered at Washington University in St. Louis, Missouri. A doctoral program in rehabilitation science is planned to begin in the near future. An interdisciplinary doctorate program in rehabilitation science was initiated by the University of Pittsburgh with the admission of eight students in the fall of 1995. An additional 10 candidates were accepted to this program in the fall of 1996. This response reflects a significant demand for advanced research degree opportunities in rehabilitation science and engineering. The establishment of these programs reflects a trend in doctoral level study in rehabilitation science in the United States. Doctoral programs in rehabilitation science are also available in Canada (e.g., University of Alberta in Edmonton, University of Toronto, and McGill University) and in Australia (e.g., Curtin University in Perth). Although these programs have taken different approaches and vary with respect to their primary areas of emphasis, all embrace the concept of rehabilitation science as a contemporary academic discipline. The emergence of rehabilitation science and engineering education at this level seems quite consistent with the conclusions reached by the committee. Such programs have been initiated because health professionals are now required to have an expanded set of skills and to work in interdisciplinary teams. The Pew Commission report Healthy America: Practitioners for 2005 (1991) challenges faculty to give students a broad understanding of the determinants of health and to prepare them to be able to work with

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--> others to integrate a range of services that promote, protect, and improve the health of the public. Students must be trained to manage and use large volumes of scientific, technological, and patient information and to address issues spanning from basic mechanisms of cellular function to applied clinical science and policy. A rehabilitation science program is needed to guide rehabilitation practice and shape policies that will improve services and access for individuals with disabling conditions. Programs in disability and rehabilitation provide students with advanced knowledge of the physiological, psychological, cognitive, social, and technological mechanisms that are related to and support the performance of individuals in everyday activities such as self-maintenance, school, work, leisure, and interaction with others. A rehabilitation science core curriculum of basic and advanced statistics and research design, measurement, and policy should link knowledge from the realms of pathophysiology, impairment, functional limitation, and disability to the performance of individuals with or at risk of developing disabling conditions. This would increase understanding of the mechanisms and issues that affect the lives of people with disabling conditions, including their specific health, work, cognitive, and social needs. Rehabilitation science programs should be supported by an interdisciplinary faculty with diverse and complementary areas of expertise to build knowledge required to understand the factors that influence and improve the function of people with disabling conditions, and prevent unnecessary disabilities through the use of modified behaviors, technology, and environmental support. Recommendations All recommendations related to rehabilitation science and engineering are based on the presumption that research and training in this field will be consistent with the model of disability and rehabilitation presented in this report. In addition, it is assumed that many academic disciplines will be involved in these recommendations. This includes some that are not traditionally associated with rehabilitation, including health services research, public health, sociology, psychology, history, economics, and political science, among others. Recommendation 9.1 Universities with extant programs in disciplines related to rehabilitation science and engineering should develop and offer doctoral and postdoctoral education in the field of rehabilitation science and engineering to help encourage the development of the field and respond to the expanding research needs.

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--> Recommendation 9.2 The federal programs that support rehabilitation-related research and training should tailor training grants to support professional education programs that integrate rehabilitation science and engineering into the knowledge base of primary care. encourage scientists from related fields to join in rehabilitation efforts to mentor rehabilitation scientists and engineering scientists in their formative years. develop new and improved mechanisms for enhancing multiperspective transdisciplinary rehabilitation-related research representing the separate perspectives of the health professional and engineering disciplines. coordinate with and develop joint efforts with programs that support training and research in the separate health professional, engineering, and preclinical science disciplines, in order to facilitate the integration and translation of rehabilitation science and engineering knowledge into the full spectrum of issues related to the health and well-being of people with disabilities, from individual clinical care to health delivery systems to social policy reform. Recommendation 9.3 Researchers conducting rehabilitation-related research in the various existing disciplines should consider how their work fits into a broader concept of rehabilitation science and engineering described in this report. Recommendation 9.4 Professional associations of rehabilitation-related disciplines (e.g., medicine, nursing, occupational therapy, physical therapy, speech-language pathology, prosthetics, orthotics, neuropsychology, and rehabilitation psychology) should collaborate in exploring opportunities to improve and enhance transdisciplinary activities among rehabilitation professionals.