1
Introduction

Advances ill rehabilitation science are essential to realizing the Nation's commitment to equal opportunity, economic self-sufficiency, and full participation of Americans with disabilities. There are important questions of the adequacy of Federal efforts in both meeting the needs of the rapidly growing number of Americans with disabilities, and in realizing the new opportunities of science and technology on behalf of people with disabilities.

—Senator Robert Dole, 1995

The United States has long judged the success of its efforts to improve the health of its citizens on the basis of mortality statistics. However, gains in human longevity have been accompanied by increases in the incidence and prevalence of chronic impairments, functional limitations, and disabilities. At this point in the evolution of the nation's health care system, emphasis has begun to shift from the quantity of life to the quality of life. As a result, attention is now being focused not only on the prevention and treatment of disease and injury but also on rehabilitation.

Rehabilitation: Concepts and Definitions

At its simplest, rehabilitation is the process of recovery from an injury. At its most complex, it is the lifelong process of obtaining ''optimal function despite residual disability" (DeLisa et al., 1993, p. 3). The range between these two extremes encompasses a wide variety of disabilities, specialties, and potential interventions. Regardless of the specific setting or circumstances, however, rehabilitation is the process by which physical, sensory, and mental capacities are restored or developed in (and for) people with disabling conditions—reversing what has been called the disabling process, and may therefore be called the enabling process. This is achieved not only through functional changes in the person (e.g., development of compensatory muscular strength, use of prosthetic limbs, and treatment of posttraumatic behavioral disturbances) but also through changes in the physical and



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--> 1 Introduction Advances ill rehabilitation science are essential to realizing the Nation's commitment to equal opportunity, economic self-sufficiency, and full participation of Americans with disabilities. There are important questions of the adequacy of Federal efforts in both meeting the needs of the rapidly growing number of Americans with disabilities, and in realizing the new opportunities of science and technology on behalf of people with disabilities. —Senator Robert Dole, 1995 The United States has long judged the success of its efforts to improve the health of its citizens on the basis of mortality statistics. However, gains in human longevity have been accompanied by increases in the incidence and prevalence of chronic impairments, functional limitations, and disabilities. At this point in the evolution of the nation's health care system, emphasis has begun to shift from the quantity of life to the quality of life. As a result, attention is now being focused not only on the prevention and treatment of disease and injury but also on rehabilitation. Rehabilitation: Concepts and Definitions At its simplest, rehabilitation is the process of recovery from an injury. At its most complex, it is the lifelong process of obtaining ''optimal function despite residual disability" (DeLisa et al., 1993, p. 3). The range between these two extremes encompasses a wide variety of disabilities, specialties, and potential interventions. Regardless of the specific setting or circumstances, however, rehabilitation is the process by which physical, sensory, and mental capacities are restored or developed in (and for) people with disabling conditions—reversing what has been called the disabling process, and may therefore be called the enabling process. This is achieved not only through functional changes in the person (e.g., development of compensatory muscular strength, use of prosthetic limbs, and treatment of posttraumatic behavioral disturbances) but also through changes in the physical and

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--> social environments that surround them (e.g., reductions in architectural and attitudinal barriers). Three other terms and concepts require definition at the outset. Rehabilitation science, as defined in this report for the first time, is the study of movement among states1 in the enabling-disabling process. This involves the fundamental, basic, and applied aspects of the health sciences, social sciences, and engineering as they relate to (1) the restoration of functional capacity in a person and (2) the interaction of that person with the surrounding environment. Engineering is the application of science and mathematics by which the properties of matter and the sources of energy in nature are made useful to people in machines, products, systems, and processes. (Rehabilitation engineering is a field of engineering that is of fundamental importance to both the restoration of function and the interaction of people with the environment.) Because of the importance of both science and engineering in advancing rehabilitation efforts and addressing the needs of people with disabling conditions, the committee uses the term rehabilitation science and engineering throughout this report to emphasize the importance of both and their synergistic contributions in the process of achieving optimal function. As originally described by Saad Nagi in the 1950s and refined most recently in the 1991 Institute of Medicine (IOM) report Disability in America, the disabling process has four major components: pathology, impairment, functional limitation, and disability (see Table 1-1). Pathology refers to molecular, cellular, or tissue changes caused by disease, infection, trauma, congenital conditions, or other factors. An example is the death of spinal cord neurons following injury. Impairment occurs at the organ or organ systems level and results in an individual's loss of a mental, physiological, or biochemical function, or abnormalities in these functions. Functional limitation is an inability or hampered ability to perform a specific task, such as climb a flight of stairs. A disability is defined as a limitation in performing certain roles and tasks that society expects an individual to perform. Disability is the expression of the gap between a person's capabilities and the demands of the environment—the interaction of a person's limitations with social and physical environmental factors. Many disabling conditions are thus preventable or reversible with proper and adequate rehabilitation, including environmental modification. A secondary condition is any additional physical or mental health condition that occurs as a result of having a primary disabling condition. Secondary conditions quite often increase the severity of an individual's disability and are also highly preventable. 1   The states in the enabling-disabling process (pathology, impairment, functional limitation, and disability) are defined below.

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--> TABLE 1-1 Concepts of Pathology, Impairment, Functional Limitation, and Disability (IOM, 1991) Pathology Impairment Functional Limitation Disability Definition       Interruption or interference of normal bodily processes or structures Loss and/or abnormality of mental, emotional, physiological, or anatomical structure or function: includes all losses or abnormalities, not just those attributable to active pathology; also includes pain Restriction or lack of ability to perform an action or activity in the manner or within the range considered normal that results from impairment Inability or limitation in performing socially defined activities and roles expected of individuals within a social and physical environment Level of Reference       Cells and tissues Organs and organ systems Organism—action or activity performance (consistent with the purpose or function of the organ or organ system) Society—task performance within the social and cultural context Example       Denervated muscle in arm due to trauma Atrophy of muscle Cannot pull with arm Change of job; can no longer swim recreationally Importance of Team Approach Effective rehabilitation addresses an individual's physical, psychological, and environmental needs in an organized and personalized manner and is not limited in the case of chronic conditions to some finite period of time following the initiation of a disabling condition. It is only appropriate, then, that an effective rehabilitation program would incorporate the views and skills of many specialists and experts working together for a common goal. Indeed, fundamental to the character and success of rehabilitation is the

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--> rehabilitation team, which often includes nurses, engineers, physicians, occupational therapists, physical therapists, physiatrists, speech-language pathologists and audiologists, psychologists, orthotists and prosthetists, and vocational counselors, among others. The rehabilitative process reflects not only the intricacies of the human but also the complex nature of disability. Rehabilitation includes both basic and applied science; it integrates human behavior and biology, medicine, health sciences and engineering; and it subsumes many disciplines in the coordination of treatment for each person. Likewise, the disabling condition rarely involves a single physiological system or falls entirely in the realm of biology. The treatment must therefore similarly affect the many facets of recovery, influencing the disabling condition, the person, and the surrounding environment. Thus, the full course of rehabilitation ideally involves a team that is simultaneously multidisciplinary, interdisciplinary, and transdisciplinary. Traditionally, these traits have defined exclusive models for team interaction. In multidisciplinary teams, for example, members work essentially singly and each participant acts as an individual consultant, evaluating the individual and providing the discipline-specific treatment recommendations. Interdisciplinary teams feature free communication between the team members to provide integrated care oriented toward the individual, and transdisciplinary teams encourage members to cross over into the traditional treatment areas of other disciplines. A fully integrated model combines each concept, drawing on many specific fields of knowledge as a single unit and synergistically producing an outcome that holistically addresses the person and the disability. The team approach is important not only in practice but also in rehabilitation research, where much of the focus is turning to disability as the result of the interaction between the characteristics of an individual with disabling conditions and the characteristics of that person's environment. Rehabilitation programs and research are beginning to emphasize the role of the environment in determining disability. As the understanding of disability changes, the rehabilitation strategies have also begun to shift toward environmental interventions. Although this concept of disability is still developing, the team approach to rehabilitation has been a part of the science since its origins. Origins of Science and Engineering in Rehabilitation Origins are almost always difficult to pinpoint. They depend on where one looks, and people looking for them often look within their own areas of expertise and within their own country of origin. French and English

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--> people may view the origin of photography differently. Similarly, French and American people may argue about the origins of cinematography. These arguments over origins appear frequently because discoveries and developments often happened in parallel in different countries, but before recent advances in travel and communications, the coincidence of these events was not known. The Beginnings Egyptian stelae and Roman mosaics have shown that technology has been used in rehabilitation since antiquity, especially by people who had undergone amputations and people who had had polio. Paintings by Brueghel the Elder show the use of a number of simple technologies in the 16th century by people with disabling conditions. Wars and conflicts have been primary stimuli for technological innovations in the rehabilitation of people with disabling injuries. The armor makers of the medieval era were skilled at making functionally effective artificial hands and leg prostheses of metal and were probably early forerunners of today's prosthetists and orthotists. In Goethe's play The Iron Hand, the noble German knight Götz von Berlichingen remarks that his iron hand had served him better in the fight than ever did the original of flesh. The Napoleonic wars fostered some technical innovations in rehabilitation, and the enormous number of amputations resulting from the U.S. Civil War more or less created the prosthetics industry in the United States. It was at that time that President Abraham Lincoln established the Veterans Administration (VA; now the U.S. Department of Veterans Affairs). At the same time, the federal government recognized the value of science to the nation, and in 1863, the National Academy of Sciences was established to be an independent, nonprofit adviser to the federal government. However, it was World War I that set the stage for the modern rehabilitation movement. Of particular note were the advances made in Germany during and following that war. Ferdinand Sauerbruch was one of the first surgeons to recommend multidisciplinary scientific and engineering endeavors in rehabilitation. In Zurich, in 1915, he worked together with Aurel Stodola, a professor of mechanics at the Polytechnical Institute of Zurich, to produce a hand prosthesis that was controlled and powered through muscle cineplasty. Sauerbruch relied heavily on muscle physiologists and anatomists to assist him with decisions about how to successfully bring muscle forces outside the body using the surgical procedure of tunnel cineplasty, a technique that he advanced at an army hospital in Germany. Sauerbruch attributed his successful implementation of this technique to the

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--> multidisciplinary approach. Speaking of this development, he said: "Henceforth, surgeon, physiologist, and technician will have to work together" (Sauerbruch, 1916). Subsequently, at the Charity Hospital in Berlin, Sauerbruch worked together with Konrad Biesalski of the Oscar Helene Heim Hospital to devise better hand replacement techniques. Biesalski developed muscle exercise and stretching equipment, which may have been some of the first physical therapy equipment, for use in training and strengthening an amputee's muscles during the period following Sauerbruch's tunnel cineplasty surgical procedures. Max Biedermann, a well-known German prosthetist, worked with them on designing and fitting arm and hand prostheses. This group worked together after World War I and was likely one of the first rehabilitation teams to work cooperatively on limb replacement. Sauerbruch considered the team approach key to his successes, which were considerable, not only with limb prostheses and rehabilitation but also open-chest surgery, which he pioneered. In addition to providing therapeutic devices, Biesalski reportedly developed the first statistics on people with disabling conditions in Germany. Consequently, Sauerbruch and Biesalski are among the earliest medical pioneers of rehabilitation science and engineering. In the United States, World War I also created a large demand for rehabilitation services as veterans with disabilities needed to be reintegrated into society and the workforce. As a result, U.S. surgeons studied surgical and prosthetic rehabilitation methods in Europe, which influenced U.S. amputation surgery practices and resulted in the greater provision of artificial limbs. Henry Kessler, an important early figure in the U.S. rehabilitation field, for example, was a proponent of Sauerbruch's methods of cineplasty. The needs of the veterans with disabilities provided fertile ground on which many different rehabilitation specialties could take root. During this period, occupational and physical therapists contributed not only to the rehabilitation of veterans with disabilities but also to the growing science underlying rehabilitation. Devices designed to measure range of motion and strength, for example, made scientific recording of specific activities possible (Hopkins, 1988). Thus, it is noteworthy that the archetypical attributes of rehabilitation science and engineering were forming simultaneously with the individual disciplines and that early rehabilitation, closely connected with surgery and physical technologies, was characterized by the use of the interdisciplinary team. The rehabilitation needs of veterans following World War I (and the need for treatment of poliomyelitis) served to stimulate the development of the field of rehabilitation as a whole. Addressing these national needs laid the groundwork for the development of many of

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--> the specialties that serve people with disabilities today. The forerunner of the American Orthotic and Prosthetic Association, for example, was formed in 1920 and the American Congress of Physical Therapy was founded the following year. This period in American history also saw the American Speech-Language-Hearing Association founded in 1925, American Congress of Rehabilitation Medicine formed in 1933, American Academy of Orthopaedic Surgery founded in 1935, and American Academy of Physical Medicine and Rehabilitation established in 1938. Box 1-1 shows a timeline for the establishment of many of the rehabilitation professional associations. Birth of Rehabilitation Science and Engineering in the United States Modalities such as heat, cold, light, water, massage, and exercise have long been used in medicine, and their use, and like that of prostheses, can be traced to antiquity. As technologies have changed new techniques and apparatuses have been added, such as electrotherapeutics, hydrotherapy, diathermy, topical application of substances, and continuous-range-of-motion machines. Through the years these modalities have been applied by different kinds of physicians, health professionals, and other people. Besides the use of physical modality therapeutic treatments, physical therapists train people to use prosthetics and orthotics to assist them with ambulation. Physical therapy originated to some extent out of physical education and gained considerable status during World War I. At that time there were physical therapy physicians, and physical therapy technicians. John Stanley Coulter, a physical therapy physician had considerable impact on the practice and professional development of the field of physical therapy and on what was ultimately to become physiatry (the name was formally recognized in 1946). The field of physical therapy grew rapidly as a result of World War I and as a result of polio treatment centers. It reached maturity during World War II. Its development paralleled the development of occupational therapy, prosthetics and orthotics, and the field of physical medicine and rehabilitation. Polio had a dramatic impact on rehabilitation in the United States, and engineering was involved with polio in an interesting way. A physical therapist, Alice Lou Plastridge, who had given President Franklin Delano Roosevelt muscle reeducation treatment, had a practice in Chicago. One of her clients who had had polio was Margaret Pope, the daughter of a wealthy Chicago hosiery manufacturer. Henry Pope was dissatisfied with the braces prescribed for his daughter and had an engineer with his company design new braces for her using aircraft construction techniques. These braces were made available to others through the Pope

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--> BOX 1-1 Establishment of Rehabilitation-Related Professional Associations 1890 American Electrotherapeutic Association 1917 American Occupational Therapy Association 1921 American Physical Therapy Association (later, the American Physiotherapy Association and then American Physical Therapy Association again) 1925 American Speech-Language-Hearing Association 1933 American Congress of Rehabilitation Medicine 1935 American Academy of Orthopaedic Surgery 1938 American Academy of Physical Medicine and Rehabilitation 1947 American Board of Physical Medicine (accrediting board) 1954 Residency Review Committee for Physical Medicine and Rehabilitation 1967 Association of Academic Physiatrists 1969 International Rehabilitation Medicine Association 1970 American Academy of Orthotists and Prosthetics 1975 American Spinal Cord Injury Association 1976 Rehabilitation Nursing Foundation 1981 Rehabilitation and Engineering and Assistive Technology Society of North America Foundation Pope also had an engineer with his company, Carl Hubbard, design the first "Hubbard tank" in 1928 A Hubbard tank is a keyhole-shaped tank for full-body immersion, used for hydrotherapy (Eisenberg, 1995) Pope and Bernard Baruch, the son of a physician/hydrotherapist at Columbia University, provided funds for Hubbard tanks to be installed in the therapy facilities at Warm Springs, Georgia Plastridge later became director of physical therapy at Warm Springs and made important advances in physical therapy Baruch would became an important supporter of rehabilitation in New York City World War II accelerated demands in military hospitals for rehabilitation professionals During this period the focus of physical medicine began to broaden from the recovery of ambulation and low-energy activities in individuals with disabling conditions to the comprehensive restoration of an individual's physical, mental, emotional, vocational, and social capacities (Kottke and Knapp, 1988). Innovators such as Howard Rusk serving in military hospitals made great strides in rehabilitation, establishing the effectiveness of active rehabilitative processes that addressed the physical and emotional needs of the soldiers over the passive, nonphysical convalescence that had been standard World War II furthermore made U.S society as a whole become aware of efforts in rehabilitation and the necessity for more advanced treatments

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--> The rise of the rehabilitation movement can be traced to efforts in many areas, and orthopedic surgeons also played a significant role. Paul B. Magnuson, a powerful Chicago orthopedic surgeon who once served injured workers at the Chicago Stockyards hired John Stanley Coulter to be the medical director of physical therapy at the Northwestern University Medical School. Besides starting the VA hospital system, Magnuson also founded the Rehabilitation Institute of Chicago and believed devoutly in vocational rehabilitation. Following World War II orthopedic surgeons influenced rehabilitation programs all across the United States, being particularly known for their work with children, human ambulation, amputation, and prosthetics and orthotics. In physiatry, Frank Krusen was one of the earliest disciples of physical medicine and he along with Henry Kessler, Howard Rusk, and George Deaver are regarded by many as pioneers of physical medicine and rehabilitation. Rusk served in the Army Air Corps as director of reconditioning and recreation. From his experiences with injured airmen, he established many of the principles of rehabilitation that were later incorporated into the programs of the Institute of Rehabilitation at New York University, an institution that had a large impact nationally and internationally on the field of rehabilitation. Rusk and Deaver, as with Sauerbruch and Biesalski before them, advocated the team approach, which has become an essential element of good rehabilitation. This work in New York and all around the country was facilitated by private citizens like Bernard Baruch and Mary Lasker. In Washington, D.C., it was supported by the VA, by the Vocational Rehabilitation Act of 1954, which permitted research and training funding for rehabilitation through the U.S. Department of Health, Education, and Welfare (DHEW), and by the Children's Bureau of DHEW. Washington, D.C., administrators like Mary Switzer and James Garrett of DHEW, Robert Stewart of the VA Prosthetics and Sensory Aids Service, and General S. S. Strong, Jr. of the National Academy of Sciences/National Research Council, Committee on Prosthetics Research and Development are just a few of the many people who played instrumental roles in launching rehabilitation in the United States. Research in rehabilitation science and engineering mushroomed after the war—stimulated partially by veteran amputees who were languishing in hospitals and who were disappointed by the state of limb prosthetics in 1945. Federal grants that funded those studies were the first such grants issued to advance science and engineering in rehabilitation. As a consequence of their lobbying, U.S. Army Surgeon General Norman Kirk called for a meeting to select which prostheses would be best for World War II veterans. That meeting, held in Chicago in January 1945, produced recommendations for scientific and engineering studies of limb prosthe-

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--> ses. The federal grants that funded those studies were the first such grants issued to advance science and engineering in rehabilitation. The early studies were dramatically successful, and the period from 1945 to 1975 was one of the most productive periods in U.S. prosthetics research. In 1945, Americans again looked to Europe for prosthetics ideas, but this time these ideas were combined with an active research and development program, coordinated by the Committee on Prosthetics Research and Development (CPRD) of the National Research Council. Since then, research and development efforts in the United States, particularly work sponsored by VA but also Army and Navy research laboratories and by the National Institute of Disability and Rehabilitation Research (NIDRR), have made the United States a world leader in the field of prosthetics and rehabilitation in general. Among the noteworthy events and achievements during this developmental phase of rehabilitation science and engineering is the 1954 publication of the classic book Human Limbs and Their Substitutes, edited by Paul E. Klopsteg, an engineer/scientist, and Philip E. Wilson, an orthopedicist/rehabilitationist and published under the sponsorship of the National Research Council (Klopsteg and Wilson, 1954). The book is a milestone of the early results of federally funded research and development in limb prosthetics. It illustrates the union of engineering and science with medicine and rehabilitation. In the foreword to that book, Detlev W. Bronk, President of the National Academy of Sciences, said, in part: Science and technology have enabled man to increase the natural powers of his body..... This notable and significant book reveals how scientists have extended that function by augmenting the powers of those whose bodies have been crippled [sic] by injury or disease.... The great accomplishments set forth in [this book] are in large part due to cooperation of physicists and surgeons, of engineers and mathematicians ... The designers of the devices and methods for rehabilitation here described have made a lasting contribution of great benefit to mankind. They have done more. They have given amputees courage and have healed the psychological trauma, which is no less grievous than the bodily loss itself. I like to think that this furtherance of spiritual well-being is the greatest contribution ... [and] deserves special comment at a time when human values could be obscured by too great emphasis on material objectives (p. vi of Foreword). The initial research work described in that book, conducted largely through the military and VA, was so successful that it was soon copied by civilian agencies and may be viewed as the beginning of most federal support involving science, engineering, and technology in disability and rehabilitation-related research. NIDRR's predecessor agencies noted the success of the prosthetics program and began funding similar research for

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--> civilian amputees. After all, the United States had more amputees resulting from war industry injuries (60,000) than from wartime combat (20,000). This expansion of services from veterans to the general public spurred an increase in research and training as the demand for new knowledge and rehabilitation professionals still outweighed the growth of each. The American Occupational Therapy Foundation, for example, was established in 1965 to advance the science of occupational therapy, supporting the education and research of its practitioners. Likewise, the Association of Academic Physiatrists was formed in 1967 explicitly to increase opportunities in research and education. In 1970, prosthetists and orthotists formed the American Academy of Orthotists and Prosthetists, and research began to expand beyond amputations to other disabling conditions such as spinal cord injury, stroke, and cerebral palsy. At about that time a new field called rehabilitation engineering began to emerge, and the field has flourished in the United States for the last 25 years, enabling many Americans with disabling conditions to have access to the leading rehabilitation technologies in the world. This did not happen by accident, but rather as a direct result of federal research and development activities, including in particular those sponsored by VA and NIDRR. Rehabilitation Science and Engineering in the U.S. Government The year 1995 marked the 75th anniversary of the passage of the Smith-Fess Act (Public Law 66-236), which originally authorized $750,000 for a program of federal grants-in-aid to state departments of education for the vocational rehabilitation of civilians (nonveterans) with disabling conditions (see Box 1-2). This ''experimental" program, administered by the Federal Board of Vocational Education, was reauthorized several times and received permanent authority (and an annual budget of $2 million) under the Social Security Act of 1935. Further amendments under the Barden-LaFollette Act of 1943 (Public Law 789-113) expanded the program to include disabled veterans and placed it under the Office of Vocational Rehabilitation (OVR). Much of the success of rehabilitation research within the OVR program in the 1950s resulted from the strong leadership of one of OVR's early leaders, Mary Switzer. Committed to the improvement of the quality of life for people with disabling conditions, she was a strong advocate for people with disabling conditions before the U.S. Congress, resulting in greatly increased budgets not only to provide rehabilitation services but also to support training programs, fellowships, and support for research in medical rehabilitation. During her administration, the concept of re-

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--> BOX 1-2 Time Line for Development of Federal Rehabilitation-Related Programs 1920 Smith-Fess Act established the Vocation Rehabilitation Program under the Federal Board of Vocational Education 1943 Barden-LaFollette Act expanded the Vocation Rehabilitation Program's scope to include physical restoration services   Office of Vocational Rehabilitation established within the Federal Security Agency Administration 1945 The Committee on Prosthetics Research and Development formed at the National Research Council 1954 The Office of Vocational Rehabilitation (OVR), under the U.S. Department of Health. Education and Welfare (HEW), expands to include private, community-based rehabilitation programs and established a research program within OVR) 1962 First rehabilitation research training centers (RRTCs) funded through the OVR research program (RRTCs at the University of Minnesota and New York University) 1963 Office of Vocational Rehabilitation is reorganized as the Vocational Rehabilitation Administration (this included a division of research with a specific appropriation for research and training grants) [Frank Corrigan, NIDRR, personal communication, 1996]) 1965 The Vocation Rehabilitation Program expands to include individuals "disabled by a lack of education and social skills." 1967 Vocational Rehabilitation Administration reorganized as the Rehabilitation Services Administration 1972 Rehabilitation Engineering Research Centers 1973 Rehabilitation Act replaces Smith-Fess Act 1978 The Rehabilitation, Comprehensive Services, and Developmental Disabilities Act becomes law   Title VII (Independent Living) is added to Rehabilitation Act   National Institute of Handicapped Research (created from Rehabilitation Services Administration Division of Rehabilitation Research) 1979 Department of Education created out of HEW   Office of Special Education and Rehabilitative Services established within Department of Education   Rehabilitation Services Administration and National Institute for Handicapped Research moved from the U S Department of Health, Education, and Welfare to Office of Special Education and Rehabilitation Services, Department of Education 1986 Amendments to the Rehabilitation Act   National Institute for Handicapped Research renamed National Institute for Disability and Rehabilitation Research 1988 Technology-Related Assistance for Individuals with Disabilities Act 1990 Americans with Disabilities Act 1991 National Center for Medical Rehabilitation Research formed within the National Institutes of Health

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--> gional rehabilitation research and training centers was adopted and funded by Congress and became a major resource for rehabilitation research and research training. An early need in the growing constellation of federal programs was simple coordination. U.S. Army Surgeon General Norman Kirk saw the need for better coordination of the emerging Army programs with those in the Office of Scientific Research and Development and VA. As mentioned previously, he asked the National Research Council to form the Committee on Prosthetic Devices—a joint effort by the Division of Medicine and Surgery and the Division of Engineering—which advised the agencies on how best to join the physicians and rehabilitation professionals with physical scientists and engineers to plan, undertake, and disseminate research. The committee lasted almost 20 years, although its name changed to the Advisory Committee on Artificial Limbs and then to the Committee on Prosthetic Research and Development, and it witnessed many changes in federal administration and organization. One of the largest changes came about as a result of the Vocational Rehabilitation Amendments of 1954 (Public Law 83-565), which instituted a multiple-program approach that included a separate system of grants for rehabilitation-related research. OVR became part of the U.S. Department of Health, Education, and Welfare and formed the National Advisory Council on Vocational Rehabilitation to review its research and training programs in rehabilitation science and engineering. In 1978, to provide a focus for these activities, the U.S. Congress created the National Institute of Handicapped Research (NIHR), which was initially staffed by researchers from OVR, the predecessor of the Rehabilitation Services Administration (RSA). Thus, by congressional action, NIHR became the lead agency for coordinating disability research, development, demonstration, dissemination, training, and related activities. Renamed NIDRR in 1986, it also has responsibility for coordinating rehabilitation research activities among other federal agencies, including the National Institutes of Health, National Science Foundation, National Aeronautics and Space Administration, and the U.S. Departments of Veterans Affairs, Education, and Labor. The Rehabilitation Act of 1973, as amended, with its authorizations for the research and other programs of RSA, expires in 1997. A thorough review and possible change can be expected under the 105th Congress in preparation for reauthorization. Origin, Scope, and Organization of the Report In light of the many and varied programs in rehabilitation research and the growing number of people with disabling conditions, Senator

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--> Robert Dole introduced the following into Senate Report 103-318, from the Committee on Appropriations: Advances in rehabilitation science are essential to realizing the Nation's commitment to equal opportunity, economic self-sufficiency, and full participation of Americans with disabilities. There are important questions of the adequacy of Federal efforts in both meeting the needs of the rapidly growing number of Americans with disabilities, and in realizing the new opportunities of science and technology on behalf of people with disabilities. The committee believes an independent assessment of the current Federal efforts in rehabilitation science and engineering is warranted and requests that the Secretary [of Health and Human Services] make appropriate arrangements with the Institute of Medicine or a similar independent entity to undertake such a review. The study should include an assessment of funding and manpower development, and make recommendations for the improvement of Federal rehabilitation science efforts (Senate Report 103-318). In response to this congressional request and subsequent negotiations with the Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services, the Institute of Medicine appointed a committee to review and consider (1) the current status of research in rehabilitation science and engineering, (2) the unmet needs of rehabilitation that require new approaches from science and engineering and that take into account the social and behavioral contexts of the individual, and (3) the best strategies for achieving the necessary level of research and medical expertise to address those needs. More specifically, the Institute of Medicine assembled a committee with expertise in rehabilitation science and engineering, health policy, basic biomedical rehabilitation and clinical research, assistive technology, social science, program evaluation, economics, and public administration and policy to address the following tasks: Assess and evaluate the current content, quality, and adequacy of the knowledge base in rehabilitation science and engineering. Therefore, in this report the committee evaluates the status of professional disciplines involved in rehabilitation science; the related needs for education, training, and research; and the potential need for a new discipline in rehabilitation science and engineering. Evaluate the utility of current rehabilitation models as they reflect the interdisciplinary and multidisciplinary nature of rehabilitation and the interaction of the person with the environment. To do this, the committee examines the integration of the various professions in rehabilitation science and considers the potential benefits of improved rehabilitation science and

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--> engineering in terms of clinical practice, individual function, quality of life, independence, and work productivity and reduced costs in health care and long-term care. Describe and recommend mechanisms for effective transfer and clinical translation of scientific findings, advances, and information that will promote health and health care for people with disabilities and disabling conditions. The committee does this by identifying obstacles and barriers to the effective translation of progress in science and clinical practice. Review and critically evaluate current federal programmatic efforts in rehabilitation science and engineering as to their productivity, relevance, and coordination. The committee thus describes potential organizational and administrative options for implementing an enhanced national program, establishes priority research categories within the context of resource limitations, and makes recommendations for enhanced coordination among federal researchers and research programs. The remainder of this report is organized into Chapters 2 to 11 and Appendixes A to D. Chapter 2 describes the magnitude, costs, and potential savings associated with disability and rehabilitation; Chapter 3 discusses a new model of the enabling-disabling process as a framework for the discussion and analyses that occur in the subsequent chapters. Chapters 4, 5, and 6 present the status and needs for research in the areas of pathology and impairment, functional limitation, and disability, respectively. Chapter 7 describes health services research in rehabilitation science and engineering. Chapter 8 discusses issues related to technology transfer, and Chapter 9 discusses education. Chapter 10 discusses the organization and administration of rehabilitation-related research in the federal government and makes recommendations for improvement. The final chapter of the report (Chapter 11) provides overarching recommendations, identifies general priorities for future research, and presents a table that shows the relationship of the overarching recommendations and general priorities to the recommendations in the preceding chapters. The appendixes present a description of the committee's data collection and analysis methods (Appendix A), summary descriptions of federal research programs in disability and rehabilitation-related research (Appendix B), a preliminary draft taxonomy (Appendix C), and brief biographies of the committee members and staff who prepared the report (Appendix D). Table 1-2 lists each of the individual tasks that the committee addresses in this report and the chapter(s) that contains the majority of the committee's response to them.

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--> TABLE 1-2 Addressing the Charge Task Committee Action Assess and evaluate the current content, quality, and adequacy of the knowledge base in rehabilitation science and engineering. • Chapters 4-6 address research and the knowledge base in each state of the enabling-disabling process (i.e., pathology, impairment, functional limitation, and disability).   • Chapter 7 discusses health services research.   • Chapter 9 discusses rehabilitation science and engineering as a scientific and academic field of study. Evaluate the utility of current rehabilitation models as they reflect the interdisciplinary and multidisciplinary nature of rehabilitation and the interaction of the person with the environment. • Chapter 3 describes current models of disability and presents the committee's enhancements for a model of the enabling-disabling process. Describe and recommend mechanisms for effective transfer and clinical translation of scientific findings, advances, and information that will promote health and health care for people with disabilities and disabling conditions. • Chapter 8 identifies both barriers and current mechanisms for technology transfer. Review and critically evaluate current federal programmatic efforts in rehabilitation science and engineering as to their productivity, relevance, and coordination. • Chapter 10 describes the federal effort in funding research in rehabilitation science and engineering, and the strengths and weaknesses of the individual programs as well as the combined, overall effort.   • Chapter 11 describes overarching recommendations and general priorities and shows their relationship to recommendations in the individual chapters.