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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

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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.

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