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Disability in America: Toward a National Agenda for Prevention
fused in flexion, not allowing proper standing and ambulation. A recent study (Yarkony and Sahgal, 1987) reported an 85 percent incidence of contractures in craniocerebral trauma cases transferred to a rehabilitation unit; frequency was related to duration of coma. In SCI and TBI patients, contractures are most effectively prevented when bed positioning and therapies to maintain motion are instituted early and are continued throughout all phases of recovery.
Pressure sores are perhaps the most commonly cited medical complication associated with SCI. Nutritional deficiency, which may be prevalent early in the conditions of TBI and SCI patients, contributes to tissue breakdown and has been found to correlate with outcome (Ragnarsson, in press). Recurrent pressure sores do occur in a small proportion of patients after discharge, and improved strategies for prevention during this phase are needed. However, proper education and training in combination with assistive equipment can be effective in preventing this condition. SCI patients suffer severe pressure sores almost twice as often before arriving at a model system care facility as after entry into the facility (Young et al., 1982).
Basic and clinical research is needed in conjunction with improvedsurveillance data to develop and improve effective interventionsfor the prevention, management, and reduction of injury-related damageto the central nervous system. In particular, emphasis should begiven to the reduction of medical complications that contribute toshort- and long-term disability in persons with SCI and TBI.
Acute (Medical) Rehabilitation
Beginning a course of rehabilitation necessitates the assessment of a person's physical and mental status. In terms of the committee's disability model, it is important to establish the stage in the progression, the risk factors, and the relevant preventive interventions. Depending on the type of impairment, for example, different interventions can be used during rehabilitation to help prevent the development of functional limitations. In persons with SCI, reduced motor power is the major cause of functional limitation. Among persons with TBI, acute weakness of one side occurs in 18 percent of cases (Eisenberg, 1985) and usually improves without contributing to significant limitation. Most functional limitations associated with severe head injury are attributable to neurobehavioral impairments (Levin, 1985; Bleiberg et al., 1989; Diller and Ben-Yishay, 1989).
Virtually all studies of rehabilitation in SCI patients are concerned with the capacity for self-care and mobility and how they relate to the severity of the neurological deficit (Ditunno et al., 1987; Welch et al., 1986; Yarkony et al., 1988). Strengthening exercises have been shown to increase motor