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OCR for page 80
6
Rehabilitation
Rehabilitation is the process by which physical,
sensory, and mental functional capacities are restored or
developed after damage. In the context of injury control,
rehabilitation is the process by which biologic, psycho-
logic, and social functions are restored or developed to
permit an injured person to achieve maximal personal
autonomy and an independent noninstitutional lifestyle.
Rehabilitation is achieved not only through functional
change in the person (e.g., development of compensatory
muscular strength, use of prosthetic limbs, and treatment
of postinjury behavioral disturbances), but also through
changes in the physical and social environment, such as
reductions in architectural and attitudinal barriers that
hamper those requir ing use of a wheelchair .
In the last decade, improvements In emergency medical
systems, in immediate management by trauma centers, and
in care of the injured en route to hospitals have
increased the survival of persons with nervous system
in jur ies, multiple in jur ies of the musculoskeletal system
and viscera, or extensive burns. Trauma units have
increased the need for defined referral to special
rehabilitation programs and follow-up services. More
persons survive major injuries, and survivors often have
severely disabling effects from the injuries themselves
and from untreated complications. Many need functional
restoration of cognition, sensation, movement control,
and mobility after brain, spinal cord, and musculo-
skeletal injury. Further negative effects on health and
performance in daily life that result from the loss of
body parts and from inactivity and immobility must be
prevented.
The increase in rate of survival after nervous system
80
OCR for page 81
81
injury was a natural consequence of the merger of medical
and allied interests, knowledge, and technologies devel-
oped during and after World War II. Experience with the
early care and rehabilitation of persons with war in jur ies
led to a new emphasis on the establishment of multidis-
ciplinary centers like the spinal cord in jury centers in
Veterans' Administration hospitals. Specialists in
physical medicine joined orthopedic surgeons in developing
restorative and reconstructive surgery. They directed
hospital units for rehabilitation. Free-standing and
hospital-based civilian rehabilitation hospitals and
centers promoted academic development by means of
exemplary service, research, and training in medical
rehabilitation, physical and occupational therapy,
rehabilitation nursing, social work, speech therapy,
psychologic services, or thotics and prosthetics, voca-
t tonal counseling, and rehabilitation engineer ing . These
specialized programs rapidly demonstrated the benefits
and loss prevention possible through the use of organized
restorative and rehabilitative care in controlling
disability and maximizing use of residual capabilities.
Rehabilitation units found improved methods for amputa-
tions, prosthetics, and management of multiple musculo-
skeletal injuries and neurotrauma. Reconstructive sur-
gical procedures evolved in orthopedic and plastic surgery
for improved function and correction of deformities.
Therapies of medical origin, physical and occupational
therapies, and psychologic, social, probational, and
behavioral techniques were developed. Peer counseling of
successfully rehabilitated persons promoted the use of
restored functions in daily life, and that led to inde-
pendent noninstitutional living. The increase in clinical
experience with major burns and their continued occurrence
in industrial and home settings promoted the development
of regional burn centers.
With comprehensive care, the profound biologic, psychos
logic, and social responses to paralysis and movement
disorder';, disfigurement, and loss of body parts are con-
trollable to a remarkable extent. Although limited
resources for clinical progress have been provided through
private and publicly supported efforts, parallel research
and educational resources for the development and dissemi-
nation of knowledge and technology have been seriously
inadequate. The development of expanded special regional
centers and programs has been lacking for the large number
of underbred persons who could benefit.
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82
The evolution of needed basic and clinical research
directed to clinical problems of rehabilitation and to
the development and application of technologies for
better mobility, environmental control, and replacement
of sensory deficits has been supported at a rate of
one-thousandth or less of the funding for research in
curative medicine. The emphasis has been on investigator-
oriented basic research, in contrast with program-oriented
and center-based cross-disciplinary research by scien-
tists, engineers, clinicians, and behavioral and social
scientists to solve problems in and evaluate postinjury
and rehabilitation care. Many important research ques-
tions and activities have been identified, but only a
small fraction are fundable in traditional ways.
The use of effective methods and procedures for
improving clinical care is not widespread. The tech-
nologies and methods of care available in trauma centers
and rehabilitation centers are available to few victims.
Failure to control the preventable consequences of injury
through treatment and rehabilitation results in a need-
less yet major health care cost to society, as well as
losses due to the effects of injury on the patient, on
the family, and ultimately, as a public and socioeconomic
burden, on all of us. Yet, for every dollar spent on
rehabilitation several dollars are saved by state and
f ederal governments.
Among persons severely disabled from all causes,
including in jury, approximately 1 in 10 of the newly
disabled uses rehabilitation facilities. There are 15
regional spinal cord injury centers, and less than 10
percent of the 5,000-10,000 persons with new spinal cord
injuries every year enter a system of care pioneered by
these centers.223 Belp to brain-injured persons is
even less.
For example, in the greater Houston area of 3.S
million persons, with three major trauma centers, the
incidence of new spinal cord injury is 50 per million of
population, or 175 persons per year added to approximately
1,500 survivors on hand. There are 5 times as many brain-
injured persons, or 87S new ones per year, with several
thousand survivors estimated.in the last decade.37 93
For the head-injured, there are only 45 organized
~center. beds in two institutions, and fewer than 100
persons are admitted per year.
Neurologic injury is probably the most costly kind of
injury and produces a great need for more organized
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83
systems of acute, subacute, restorative, and rehabili-
tative care. As with burn care, such a system must build
on specialized knowledge, skills, experience, and tech-
nology with continuity of service and follow-up. Rehab-
ilitation and independent-living service can provide
deinstitutionalization for more than three-fourths of the
patients; the cost of this over a lifetime is estimated
at one-tenth the cost of custodial care with repeated
hospitalizations. ~ 2 0 ~ 3 3
The data base for the spinal cord in jury center
program among the 15 regional centers revealed that the
intake and follow-up process sacred one-third of first-
cost dollars, achieved home placement in 85 percent of
over 6, 000 f irst admissions, and decreased the incidence
of complications and later hospitalizations for complica-
tions.2 2 3 The relatively low incidence and prevalence
of necrologic injuries, multiple musculoskeletal injuries,
and burns fail to imply how important and costly the
problems that result can be. In fact, this situation is
the emerging important issue of injury. The 'social and
economic impacts on the patient, the family, the com-
munity, and the state and nation are substantial. There
are no aggregate statistics on the lifetime impact of
these conditions. The problem has become more frequent
and complex in the last 10 years, because survival with
residual disability of the injured has increased. There
is no mandatory reporting for even the occurrence of
these conditions or the attendant disability, as there is
for births, deaths, or even vehicle registration. We
count expenditures as health care costs and transfer
payments for disability. But we have failed to use losses
prevented and costs decreased by improved care as factors
in benefit-versus-cost estimates for rehabilitation.
Accounting must omit the intangible and the uncounted.
Yet, the consequences are found in the fabric and
activities of our family life, our productivity, and our
community life and in the loss of pr ide in connection
with the values we profess as a nation--independence,
quality of life, and pursuit of the opportunity to be an
equal member of society. Perhaps the implicit threat of
disability, unlike the inevitability of death, is a
hidden concern that causes us to turn our beads away from
its possibility until it strikes us or one we know and
love. Because of the current long-term survival with
disability, we cannot afford to be unprepared to prevent
the losses of function after injury.
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84
RESEARCH ISSUES AND NEEDS
Proper and enlightened management during pickup and
delivery to trauma centers and during hospital care can
profoundly reduce the extent of disability and prevent
complications that would retard later rehabilitation.
Therefore, rehabilitation of an in jured patient and
prevention of and early care for injuries pose insepar-
able questions for research policy. The goal of injury
care should be not simply to achieve medical stabiliza-
t~on, but rather to minimize disabling effects and come
plications. The goal is not accomplished fully until the
injured person achieves the maximal possible functional
ef festiveness in all aspects of life, including daily
living, work, education, and recreation. Systems of care
for patients with spinal cord injuries that coordinate
management from the site of the injury through trauma
center care, intensive rehabilitative treatment, and
transitional services, to independent living are proving
more humane and cost-effective than uncoordinated
effOrtS.64 133 IS2
Too often, knowledge of effective rehabilitation goes
unused. The following discussion illustrates the
spectrum of issues and conditions that requires both
research and the application of existing knowledge.
Musculoskeletal In jut ies
Musculoskeletal incur ies are among the most common
injuries. Evaluations of causes of work disability
indicate that, in persons 16-65 years old musculo-
skeletal conditions are the predominant cause of loss of
work and eligibility for social security disability
benefits and unemployment compensation. Back disorders
are most common, but serious musculoskeletal injuries are
apt to prolong dinability--fractures, amputations, and
band injuries. According to a recent document of the
American Academy of Orthopedic SurgeonsS on current and
future research needs, Approximately one of every eight
beds in general hospitals in the United States is occupied
by an accident victim, and injuries involving the mus-
culoakeletal system are the most frequent sustained by
that group of victims.. These injuries include joint
dislocations, extensive soft-tissue swelling, rupture of
tendons, injuries to nerves, and damage to major blood
vessels. This document further states: Approximately
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85
sixteen million significant upper extremity injuries
occur each year, which are responsible for ninety million
days of restricted activity and sixteen million days of
lost work. Similarly, injuries to the musculoskeletal
system are the commonest injuries in athletics and sports
recreation. Spinal cord injury associated with athletic
and recreational activities accounted for 12 percent of
5,635 cases of spinal cord injury in which patients were
rehabilitated in spinal cord injury centers from 1973 to
1981. 2 2 3 Musculoskeletal and necrologic in jur ies of
all types result in severe work disability (65 percent)
in our working-age population (127~1 million persons in
the United States in 1978)e The other personal and
family losses are inestimable, uncounted, ~ ~ s but real .
Pathophys iology of Sof t-Tissue In jury and Nerve
Regeneration
Effects of soft-&cissue trauma at the molecular and
cellular levels overlap basic research on tissue injury
described in Chapter 5. Studies on the pathophysiology
of muscle, nerve, and microcirculatory (and lymphatic)
systems dur ing and after increases in tissue pressure are
needed. Mechanisms of nerve regeneration and repair in
the peripheral nervous system and the effect of elec-
tricity on nerve regeneration have been insufficiently
studied.
Fracture Healing Processes
Fracture healing processes are not fully understood.
Research is needed on injured bone with regard to the
origin of the precursor cell of osteogenesis, the
chemical nature of the bone-inducing substance(~), its
mechanism of action, the organic matrix elements of bone,
and the cellular control mechanisms of bone
mineralization.
Fracture Nonunion
Nonunion, or failure of a fracture to heal, is a
serious and disabling complication of fracture repair.
Studies of causes and predisposing factors are needed,
with evaluation of treatment. The usefulness of engineer
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86
ing techniques for prevention or treatment analysis, the
effect of bioelectricity, and the development of biomater-
ials that could bridge nonunion sites and promote bone
growth are important in restorative surgery and for
restoration of function.
Microsurgical Techniques
Replantstion of amputated parts and transplantation of
vascularized and innervated muscle and bone flaps can be
improved. Tissue perfusates and microvascular repair
techniques that promote healing need to be identified.
Structural and Ultrastructural Anatomy
Efforts to identify the structural and ultrastructural
anatomic details of bone, disk, ligaments, and joints of
the spine need support. Measurements of motion in normal
and injured states in all spinal segments and knowledge
of muscular control of segmental motion are needed for a
mathematical model to test effects of forces, loads, and
supports.
B ioengineer ing and Biomater ials
Ideas and technologies are needed to predict the
interaction of artificial materials and structures with
natural biologic tissues - such as cortical bone, can-
cellous bone, and cartilage--so that the effects of
metallic internal f ixation devices, joint prostheses,
etc., can be learned. }mproved designs and fixation
factors of prosthetic devices are needed. Studies are
needed for measurement of real forces and motion patterns
and for testing the strength and fatigue of prosthetic
components. Use of theoretical modeling techniques
should be explored to improve configuration, positioning,
and interface characteristics of prosthetic implants.
Burns
Burns accounted for 100,000 hospitalizations in 1976,
according to the only recent study (C. D. Herndon,
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87
personal communication). It was estimated that 50,000
persons per year were disabled because of burns.
In the opinion of physicians specializing in burn
therapy, there have been few advances in treatment of
inhalation injuries in the last 20 years (C. D. Herndon,
personal communication; Michigan Burn Data Exchange
Center, personal communication). Extensive rehabilitation
is required of survivors of major burns to control con-
tractures that limit, for example, useful hand and arm
movements, facial expression, and intelligible speech.
Therapy is needed to minimize scarring and thus permit
mobilization of joints after surgery; disfigurement
hinders social acceptance of the burn victim. Specialized
resources for comprehensive burn treatment and rehabilita-
tion were first established by the military, and more
recently centers were established for children by the
Shriners. Several tertiary referral hospitals with burn
centers have added burn rehabilitation programs, as have
some rehabilitation centers. An accessible rational
system does not exist for all burn victims.
Many experts in this field consider research needs to
be extensive and greatly underfunded. There have been
very few rehabilitation-related research efforts. Most
research has been related to grafting and debridement
techniques and the management of acute injury. There is
need for evaluation of alternative methods of management
both immediately after injury and later.
Pathophy~iology of Fire-Related Gas Inhalation
Basic and clinical research on the pathophysiology and
treatment of pulmonary insufficiency and failure caused
by inhalation of toxic fire-related gases- the greatest
cause of death from fires--is urgently needed. Long-term
pulmonary scarring and ventilatory insufficiency greatly
affect exercise capacity and need to be minimized for
ef festive rehabilitation.
Problems in Cutaneous Debridement and Replacement
Clinical research for comparative evaluation of
long-term disabling effects of alternative methods of
debridement--early and late and with different techniques
to identify viable tissue in third-degree burns with
early debridement of dead tissue--is important for
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88
successful grafting and control of extent of debridement
and secondary infection. More research on technology for
mass production of homologous skin-cell culture, etc., is
needed.
Prevention and Control of Tissue Contractures and
Hypertrophic Scarring
Comparative evaluation of methods for control of
contracture formation--e.g., early splinting and pressure
bandaging--is needed, as well as basic research on
methods for inhibition of excessive collagen formation in
scarring.
Disabling Pain
Disabling pain that retards activity, purposeful
movements, and ambulation and that is occasioned by
dress ing changes, periodic debridement, reconstructive
surgery, and grafting requires basic and clinical
research on alternative methods of pain control,
including electric stimulation of the spinal cord.
Psychosocial Research and Prosthetic Methods
There has been little research on the behavioral and
social aspects of burn disfigurement with respect to
patient reactions and effects on parents and siblings--
e.g., the consequences for schooling and vocational
opportunities. Children seem to adapt better than
adults, but the reasons are not known. The role of
facial and missing-part prostheses has not been evaluated
on the basis of materials, cosmetic-success, utility, eta
Second Injury of the Spinal Cord
Second injury of the spinal cord after injury of the
neck vertebrae is tragic, not uncommon, and preventable
Second injury can occur at the time of emergency pickup,
during initial emergency hospital treatment and evaluation
(e.g., during x-ray examinations), and even later, as
a result of failure to recognize severe vertebral
instability.
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89
Major malpractice suit settlements often result from
f se' ure to prevent second in jury. For example, in 1975 a
judgment of approximately SI. 5 million was awarded
against a Veterans' Administration hospital for its
involvement in causing second injury to a patient with
neck instability after a motor-vehicle collision. 5 S
That award equals approximately one-fifth of the entire
1984 Veterans' Administration budget for rehabilitation
and engineering research.
Training
Training of ambulance and emergency medical technicians
and emergency room stat f and technicians can reduce the
f requency of second in jury.
Tr anspor tation
Devices for safer transport of neck-and-head-in jured
persons are being developed and need to be evaluated,
produced, and distributed, but little or no funding is
available.
Preservation of Spinal-Cord Function
Not all injured spinal cords believed to be completely
severed are devoid of residual functional neuroses and
connections to higher levels of the brain and lower levels
of the spinal cord. Recent clinical neurophysiologic
research on 2,000 persons with spinal cord injuries teas
shown that nearly two~thirds of so-called complete
injuries, in fact, are not complete. s ° Involuntary-
m,vement disorders like spasticity overlie and conceal
residual voluntary-moven~ent control and sensory
f unctions . Even late disorders of the in jured spinal
cord, such as dissecting cystic swelling in the central
cord, can be diagnosed early and treated surgically to
limit further loss of function.
The scientific and intellectual effort required to
~cure. spinal cord injury is akin to a total cure of
cancer in scope and resource needs. It represents one
end of the spectrum of research need. Waiting for a
~cure. will leave millions of persons unable to achieve
what human adapative capacities make possible with proper
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so
rehabilitation, a less handicapping living environment,
and an opportunity to recover personal autonomy through
control of one's life. Both basic experimental research
and clinical neurophysiologic studies of persons with
brain and spinal cord injury reveal extraordinary
adaptability of the brain. Recovery of lost motor
control, control of abnormal central nervous system
activity, and training for motor relearning through the
use of other systems and pathways of the nervous system
are all feasible to a degree--generally unrecognized and
rarely facilitated. These become the new potential
processes for improving basic human adaptability.
Preservation of Residual Function
Much research remains to be done on preservation of
residual function and control of necrologic functional
disturbances to regain bladder control and useful
movement.
Nerve Regeneration
Basic animal research has already demonstrated some
features of central nervous system regeneration. Tissue
implants of per ipheral nerves in the central nervous
system show some potential for reconnection across
surgically produced gaps in neural connections.
Pressure Sores
Failure to prevent pressure sores in the acute phase
of injury or at any time during the course of disability
creates misery, debilitation, and social and economic
losses. This entirely preventable complication occurs in
35-40 percent of persons with spinal cord injury who beve
sensory and motor losses.22' It may develop in the
first weeks after injury or later, even in young adults
actively engaged in school, work, and recreation. It is
very common among elderly bedridden persons in custodial
care. The costs of hospitalization, surgical skin repair,
and control of infection (which can proceed to chronic
severe osteomyelitis, even requiring amputation) now
average S2S.000-S28.000 per pressure sore.~02 An
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91
estimate of the direct costs in hospital and medical car e
is about S1.5 billion a year . The magnitude of loss of
income due to prolonged and recurrent hospitalization is
unknown, but is at least as much.
Management of Pressure Sores
More clinical research, development of care systems
that use what is known, and augmentation of training are
urgently needed.
Consequences of In judicious In jury Care
The failure to anticipate and prevent a var iety of
metabolic, circulatory, respiratory, genitourinary, and
musculoskeletal consequences of inactivity and immobility
prolongs expensive care, delays active rehabilitation,
and leads to failure to regain a state of health and
preservation of residual functional capacity for purpose-
ful activities. Injudicious timing of surgical interven-
tion can augment postinjury stress responses and lead to
such life-threatening complications as massive bleeding,
uncontrollable infections, and respiratory insufficiency
and failure.
Management of Sequelae
Re~searab i'; needed on ways to protect residual neural
tissue friability and to control `;er ious complications
that make rehabilitation difficult or impossible.
CONCLUSIONS
A national effort is needed to achieve appropriate
empha'; is on disability-related teas lo and applied
research, technologic research and development, service
systems, education and training, and social understand-
ing. Great savings and increased quality of life would
result from improved application of what is already
known, but there in a need for substantial increases in
research in many subjects. Table 6-1, at the end of the
chapter, ';wmnarizes what is known and what is needed in
rehabilitation research.
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92
The prevention of disability provides some of the
economic fuel for continued research on long-term
approaches to minimizing the costs and losses incurred in
disability. Social and economic losses due to injury-
initiated disability and chronic medical care and
institutionalization could be prevented, and that would
yield funds for other health purposes. In addition,
restructuring of the physical environment to reduce
social and economic losses caused by failure to include
handicapped persons of all ages in community life will
help in jury victims. Long-term institutional ization of
able-bodied young adults who could be self-auf f icient
the poorest possible solution, but it is the most
f request one today.
RECOMMENDATIONS
The following are some recommendations that, if
implemented, would substantially reduce disability due to
injury in this country. Not all are stated in the form
of researchable questions, although many lend themselves
to various kinds of research, demonstrations, evaluations,
and increased use of existing knowledge. Research is not
the sole solution to key issues in public policy needed
for control of a problem as complex as comprehensive
rehabilitation of injury victims.
1. Major research centers should be developed for
clinical neurophysiology programs on evaluation and
management of neural injury residue, neural system
function, and technologic replacement of lost function.
2. Funding priority should be given to research on
the identification and preservation of residual func-
tions, development of substitute functions, psychosocial
management of the patient and family, and deinstitu-
tionalization.
3. Research programs aimed at minimizing the effects
of injury to the musculoskeletal system, including both
bone and soft tissue, that result from physical, chemical,
and thermal causes should be promoted.
4. Research programs should be established in the
behavioral and social sciences for cross-disciplinary
studies of adaptive behavior and its relationship to
brain function in environmental adjustment and learning.
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93
5. Wider application of existing knowledge related to
r ehabilitation and prevention of second in jury is needed .
6. Development and evaluation of model systems of
rehabilitation should be promoted.
7. Research should be greatly expanded on behavioral
and social factors related to stigmatization of and
discr imitation against the disabled .
8. A system is needed that can identify disabled
persons and persons with in jur ies that are likely to
produce severe disability, so that services for those who
might benefit can be planned. Linked local, regional,
and national reporting systems for the disabled are
necessary to go beyond social security studies limited to
work disability; these systems could be built into the
surveillance system recommended in Chapter 2 .
9. Hospitals and physicians and surgeons managing
injury cases should be provided with communication
networks for reporting, obtaining information, and
arranging tz iage , therapy, and referral.
10. Professional education and exper fence should be
revised to include familiarity with model trauma centers
and comprehensive rehabilitation centers.
OCR for page 94
94
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Representative terms from entire chapter:
cord injury
