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Page 1: Springer Series on Rehabilitation - Nexcess CDNlghttp.48653.nexcesscdn.net/80223CF/springer... · topics including orthopedic impairments, stroke, brain injury, pain, and wound care
Page 2: Springer Series on Rehabilitation - Nexcess CDNlghttp.48653.nexcesscdn.net/80223CF/springer... · topics including orthopedic impairments, stroke, brain injury, pain, and wound care

Springer Series on Rehabilitation

Myron G. Eisenberg, PhD, Series EditorVeterans Affairs Medical Center, Hampton, VA

Thomas E. Backer, PhD, Consulting EditorHuman Interaction Research Institute, Los Angeles, CA

2005 Medical Aspects of Disability, Third Edition: AHandbook for the Rehabilitation Professional

Herbert H. Zaretsky, PhD, Edwin F. Richter III, MD, andMyron G. Eisenberg, PhD, Editors

2004 Families Living With Chronic Illness and Disability:Interventions, Challenges, and Opportunities

Paul W. Power, ScD, CRC,and Arthur E. Dell Orto, PhD, CRC

2004 Counseling Theories and Techniques for RehabilitationHealth Professionals

Fong Chan, PhD, Norman L. Berven, PhD, and Kenneth R. Thomas, DEd, Editors

2004 Handbook of Rehabilitation CounselingT.F. Riggar, EdD, and Dennis R. Maki, PhD, CRC, NCC , Editors

2004 Psychology of Disability, 2nd Ed.Carolyn L. Vash, PhD, and Nancy M. Crewe, PhD

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MedicalAspectsDisability3rd Edition

A Handbook for the RehabilitationProfessional

Herbert H. Zaretsky, PhDEdwin F. Richter III, MDMyron G. Eisenberg, PhDEditors

of

Springer Publishing Company

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Herbert H. Zaretsky, PhD, is currently Administrator, Department ofRehabilitation Medicine at the Rusk Institute, New York University Medical Center,and Clinical Professor of Rehabilitation Medicine at the New York University Schoolof Medicine. He received his PhD from Adelphi University. Dr. Zaretsky has pub-lished extensively in the field of rehabilitation in such areas as psychological aspectsof disability, geriatric rehabilitation, learning and conditioning with the neuro-logically impaired and spinal-cord injured, rehabilitation psychology and long-termcare of the chronically ill, chronic pain management, and behavioral medicineapplications to rehabilitation. Dr. Zaretsky is a Fellow of the American PsychologicalAssociation (APA), Past President of APA’s Division of Rehabilitation Psychology, anda recipient of the APA’s Distinguished Contribution to Rehabilitation PsychologyAward. Dr. Zaretsky was formerly Chair of the Board of Trustees of the Commissionon Accreditation of Rehabilitation Facilities (CARF) and recently its Past-Chair. Heis a member of the Board of Directors of the American Cancer Society’s (ACS)Eastern Division (New York/New Jersey), recently served as the Board’s Treasurer,is currently a National Division Delegate of the ACS National Assembly, and is therecipient of the St. George Medal, a national award from the ACS in recognition foroutstanding contributions to the control of cancer.

Edwin F. Richter III, MD, is Clinical Associate Professor of Rehabilitation Medicineat New York University School of Medicine and Associate Clinical Director of theRusk Institute of Rehabilitation Medicine. He received his MD from New YorkUniversity School of Medicine and continued residency training there. He is aFellow of the Academy of Physical Medicine and Rehabilitation. He has publishedand presented extensively in the field of physical medicine and rehabilitation ontopics including orthopedic impairments, stroke, brain injury, pain, and woundcare. He serves as director of the Stroke Rehabilitation Program, the Mild TraumaticBrain Injury Program, and the Adult Spasticity Clinic at the Rusk Institute ofRehabilitation Medicine, and is Chairman of the Advisory Board of the BrainInjury Society.

Myron G. Eisenberg, PhD, is Director of Psychological Services and Director ofResearch Services at the Department of Veterans Affairs Medical Center in Hampton,VA, and is Associate Professor of both Physical Medicine and Rehabilitation and ofPsychiatry and Behavioral Sciences at Eastern Virginia Medical School, Norfolk.Additionally, Dr. Eisenberg is the Associate Chief of Staff for Education and Researchat the Hampton VA Medical Center, and the Education Manager for the VeteransAdministration’s Mid-Atlantic Health Care Network which includes eight MedicalCenters in Virginia, West Virginia and North Carolina. He obtained his PhD fromNorthwestern University and received postdoctoral training at the University ofToronto’s Clarke Institute. Dr. Eisenberg has published extensively in the area of reha-bilitation, holds editorial board positions on several journals, is the immediate pastEditor of Rehabilitation Psychology, and is a member of several national task forcescharged with investigating various quality-of-life issues of importance in personswith chronic disabling conditions. Dr. Eisenberg has received recognition at thelocal, regional, and national level for contributions he has made to the rehabilita-tion of persons with physical impairments. A Fellow and Past President of theAmerican Psychological Association’s Division of Rehabilitation Psychology, he isactively involved in heightening the public’s awareness of the importance of reha-bilitation through the promotion of research.

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Copyright © 2005 by Springer Publishing Company, Inc.

All rights reserved

No part of this publication may be reproduced, stored in a retrieval system,or transmitted in any form or by any means, electronic, mechanical, photo-copying, recording, or otherwise, without the prior permission of SpringerPublishing Company, Inc.

Springer Publishing Company, Inc.11 West 42nd StreetNew York, NY 10036-8002

Acquisitions Editor: Lauren DockettProduction Editor: Pamela LankasCover and page design by Reyman Studio

05 06 07 08 09/5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Medical aspects of disability : a handbook for the rehabilitationprofessional / Herbert H. Zaretsky, Edwin F. Richter, Myron G. Eisenberg,editors.-- 3rd ed.

p. ; cm. -- (Springer series on rehabilitation)Includes bibliographical references and index.ISBN 0-8261-7973-8 (hardcover)

1. Medical rehabilitation. 2. Chronic diseases. 3. Disabilityevaluation.

[DNLM: 1. Disabled Persons--rehabilitation. 2. Disability Evaluation. 3.Rehabilitation--methods. WB 320 M48872 2005] I. Zaretsky, Herbert H. II.Richter, Edwin F. III. Eisenberg, Myron G. IV. Springer series onrehabilitation (Unnumbered)

RM930.M42 2005617'.03--dc22

2005005046

Printed in the United States of America by Sheridan Books

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Editorial Advisory Board

Constance Corley, MSW, PhDAssociate Professor

School of Social WorkUniversity of Maryland

Howard Thistle, MDAssociate Professor of Rehabilitation Medicine and Clinical Director

Rusk InstituteNew York University Medical Center

Victoria L. Champion, RN, DNS, FAANProfessor and Associate Dean for Research

School of NursingIndiana University, Purdue University

Indianapolis, IN

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PART IAn Introduction to Key Topics and Issues

1. Comprehensive RehabilitationThemes, Models, and Issues Robert Allen Keith, PhD, and Harriet Udin Aronow, PhD . . . . 3

2. Body SystemsAn OverviewJung H. Ahn, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

PART II Disabling Conditions and Disorders

3. Acquired Immune Deficiency Syndrome and Human Immunodeficiency VirusJames Satriano, PhD, Alan Berkman, MD, andRobert H. Remien, PhD . . . . . . . . . . . . . . . . . . . . . . . . 59

4. Alzheimer’s DiseaseBarry Reisberg, MD, Ali Javed, MD, Sunni Kenowsky, DVM, and Stefanie R. Auer, PhD . . . . . . . . . . . 79

Contents

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5. Traumatic Brain InjuryThomas M. Dixon, PhD, Barry S. Layton, PhD, and Rose Mary Shaw . . . . . . . . . . . . . . . . . . . . . . . . 119

6. Burn InjuriesEdwin F. Richter III, MD . . . . . . . . . . . . . . . . . . . . . . 151

7. Cancers Ingrid Freidenbergs, PhD, Ilana Grunwald, PhD, and Esin Kaplan, MD . . . . . . . . . . 159

8. Cardiovascular DisordersMariano J. Rey, MD . . . . . . . . . . . . . . . . . . . . . . . . . 179

9. Chronic Pain SyndromesAndrew R. Block, PhD, Edwin F. Kremer, PhD, and Ann M. Kremer, PhD . . . . . . . 213

10. Diabetes MellitusDavid G. Marrero, PhD, and John C. Guare, PhD . . . . . . . 241

11. EpilepsyRobert T. Fraser, PhD, CRC, and John W. Miller, MD . . . . . 267

12. Speech, Language, Hearing, and Swallowing DisordersPatricia Kerman Lerner, MA, and Nancy Eng, PhD . . . . . . 289

13. Hematologic Disorders Bruce G. Raphael, MD . . . . . . . . . . . . . . . . . . . . . . . 325

14. Developmental DisabilitiesRichard J. Morris, PhD, Yvonne P. Morris, PhD, and Priscilla A. Bade White, PhD . . . . . . . . . . . . . . . . 343

15. Neuromuscular Disorders Ludmilla Bronfin, MD . . . . . . . . . . . . . . . . . . . . . . . 383

16. Orthopedic ImpairmentsEdwin F. Richter III, MD, and Robert DePorto, DO . . . . . . . 411

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17. Ostomy SurgeriesLes Gallo-Silver CSW-R, ACSW, Diane Maydick-Youngberg, MS, RN, CWOCN, and Michael Weiner, MSW . . . . . . . . . . . . . . . . . . . . . . . 427

18. Pediatric DisorderCerebral Palsy and Spina Bifida Joan T. Gold, MD . . . . . . . . . . . . . . . . . . . . . . . . . . 443

19. Peripheral Vascular DisordersGlenn R. Jacobowitz, MD. . . . . . . . . . . . . . . . . . . . . . 495

20. Psychiatric Disabilities Gary R. Bond, PhD, Kikuko Campbell, and Natalie DeLuca . . . . . . . . . . . . . . . . . . . . . . . . 509

21. Pulmonary DisordersFrederick A. Bevalaqua, MD, and Francis V. Adams, MD . . . 543

22. Chronic Kidney DiseaseKotresha Neelakantappa, MD, and Jerome Lowenstein, MD . . . . . . . . . . . . . . . . . . . . 563

23. Rheumatic DiseasesSicy H. Lee, MD, and Steven B. Abramson, MD . . . . . . . . . 583

24. Spinal Cord Injury Alan W. Heinemann, PhD, ABPP, and Purva H. Rawal, MA . . . . . . . . . . . . . . . . . . . . . . 611

25. HemiplegiaLeonard Diller, PhD, and Alex Moroz, MD . . . . . . . . . . . 649

26. Substance Use Disorders in RehabilitationConstance Saltz Corley, MSW, PhD, Marcia Lawton, PhD, and Muriel Gray, PhD. . . . . . . . . . . 675

27. Visual Impairments Bruce P. Rosenthal, OD, FAAO, and Roy Gordon Cole, OD, FAAO . . . . . . . . . . . . . . . . . 695

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PART III Special Topics

28. Alternative Medicine and Its Relationship to RehabilitationMary F. Bezkor, MD, and Mathew H. M. Lee, MD. . . . . . . . 725

29. Rehabilitation NursingEducating Patients Toward Independence Jeanne Dzurenko, RN, MPH . . . . . . . . . . . . . . . . . . . . 737

30. Social Work and Rehabilitation Esther Chachkes, DSW . . . . . . . . . . . . . . . . . . . . . . . 751

31. Telerehabilitation – Solutions to Distant and International Care Andrew J. Haig, MD. . . . . . . . . . . . . . . . . . . . . . . . . 769

32. The Computer Revolution and AssistiveTechnology Leonard Holmes, PhD . . . . . . . . . . . . . . . . . . . . . . . . 783

33. Trends in Medical Rehabilitation Delivery and Payment Systems Kristofer J. Hagglund, PhD, Donald G. Kewman, PhD, Nancy E. Wirth, MD, and Steven C. Riggert, PhD . . . . . . . 797

34. Legislation and Rehabilitation ProfessionalsSusanne M. Bruyere, PhD, and Sara A. Nan Looy. . . . . . . . 827

35. Accreditation – A Quality Framework in theConsumer-Centric Era Brian J. Boon, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . 851

36. Outcomes Measurement and QualityImprovement in an Acute Inpatient Rehabilitation Setting Ora Ezrachi, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . 879

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891

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Steven R. Abramson, MDProfessor of Medicine and

PathologyNew York University School of

MedicineHospital for Joint DiseasesNew York, NY

Francis V. Adams, MDClinical Assistant Professor of

MedicineNew York University School of

MedicineNew York, NY

Jung H. Ahn, MD Clinical Professor of

Rehabilitation MedicineNew York University School of

MedicineRusk Institute of Rehabilitation

MedicineNew York, NY

Harriet Udin Aronow, PhD, Director of Research Casa Colina Centers for

RehabilitationPomona, CA

Stefanie R. Auer, PhDMorbus Alzheimer AssociationAustria

Alan Berkman, MDMedical SpecialistHIV Center for Clinical and

Behavioral StudiesNew York State Psychiatric

Institute and ColumbiaUniversity

New York, NY

Frederick A. Bevalaqua, MDClinical Assistant Professor of

MedicineNew York University School of

MedicineNew York, NY

Contributors

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Mary F. Bezkor, MDClinical Associate Professor of

Rehabilitation MedicineNew York University School of

MedicineRusk Institute of Rehabilitation

MedicineNew York, NY

Andrew R. Block, PhDDirectorThe Well-Being GroupPlano, TX

Gary R. Bond, PhDProfessor of PsychologyIndiana University—Purdue

University at IndianapolisIndianapolis, IN

Brian J. Boon, PhDPresident/CEOCommission on Accreditation of

Rehabilitation FacilitiesTucson, AZ

Ludmilla Bronfin, MDAssistant Professor of NeurologyNew York University School of

MedicineNew York, NY

Susanne M. Bruyere, PhDDirector, Program on

Employment and DisabilitySchool of Industrial and Labor

RelationsCornell UniversityIthaca, NY

Kikuko Campbell Indiana University—PurdueUniversity at IndianapolisIndianapolis, IN

Esther Chachkes, DSWClinical Associate Professor of

Social WorkNew York University School of

Social WorkFaculty, End of Life Certificate

ProgramSmith College School of Social

WorkDirector of Social Work and

Therapeutic RecreationNew York University Medical

CenterNew York, NY

Roy Gordon Cole, OD, FAAODirector of Vision Program

DevelopmentThe Jewish Guild for the BlindNew York, NY

Constance Saltz Corley, MSW, PhD

Professor and Associate Directorof Research

Csula Roybal Institute forApplied Gerontology

University of California Los Angeles, CA

Natalie DeLucaIndiana University—Purdue

University at IndianapolisIndianapolis, IN

Robert DePorto, DOClinical Assistant Professor of

Rehabilitation MedicineNew York University School of

MedicineRusk Institute of Rehabilitation

MedicineNew York, NY

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Leonard Diller, PhDProfessor of Rehabilitation

MedicineNew York University School of

MedicineDirector of PsychologyRusk Institute of Rehabilitation

MedicineNew York, NY

Thomas M. Dixon, PhDAssistant Professor of Physical

Medicine and RehabilitationCase Western Reserve University

Staff PsychologistCleveland VA Medical CenterCleveland, OH

Jeanne Dzurenko, RN, MPHDirector of NursingRusk Institute of Rehabilitation

MedicineNew York University Medical

CenterNew York, NY

Nancy Eng, PhDAssociate ProfessorDepartment of Speech,

Communication Sciences, and Theater

St. John’s UniversityJamaica, NY

Ora Ezrachi, PhDClinical Assistant Professor of

Rehabilitation MedicineDepartment of Rehabilitation

MedicineNew York University Medical

CenterManager, Program Outcomes Rusk Institute of Rehabilitation

MedicineNew York, NY

Robert T. Fraser, PhD, CRCProfessorDepartments of NeurologyUniversity of WashingtonSeattle, WA

Ingrid Freidenbergs, PhDClinical InstructorDepartment of PsychiatryNew York University School of

MedicinePsychologistRusk Institute of Rehabilitation

MedicineNew York, NY

Les Gallo-Silver, CSW-R, ACSWNew York University Medical

CenterNew York, NY

Joan T. Gold, MDClinical Associate Professor of

Rehabilitation MedicineNew York University School of

MedicineClinical Director of Children’s

Rehabilitation ServicesRusk Institute of Rehabilitation

MedicineNew York, NY

Muriel Gray, PhDAssociate ProfessorSchool of Social WorkUniversity of MarylandBaltimore, MD

Ilana Grunwald, PhDClinical Instructor of

Rehabilitation MedicineNew York University School of

MedicineRusk Institute of Rehabilitation

MedicineNew York, NY

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Co n t r i b u t o r s

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John C. Guare, PhDSenior Lecturer, Department of

PsychologyIndiana University—Purdue

University of IndianapolisIndianapolis, IN

Kristofer J. Hagglund, PhDAssociate Dean of Health Policy

and Academic AffairsCo-Director, Center for Health

PolicySchool of Health ProfessionsUniversity of Missouri—

ColumbiaColumbia, MO

Andrew J. Haig, MDAssociate ProfessorPhysical Medicine and

Rehabilitation andOrthopedic Surgery

The University of MichiganAnn Arbor, MI

Allen W. Heinemann, PhD,ABPP

Professor, Physical Medicine andRehabilitation

Feinberg School of Medicine,Northwestern University

Director, Center forRehabilitation Outcomes

ResearchRehabilitation Institute of

ChicagoChicago, IL

Leonard Holmes, PhDVeterans Affairs Medical CenterHampton, VA

Glenn R. Jacobowitz, MDAssistant Professor of SurgeryDivision of Vascular SurgeryNew York University Medical

CenterNew York, NY

Ali Javed, MDClinical Research FellowSilberstein Aging and Dementia

Research CenterNew York University School of

MedicineNew York, NY

Esin Kaplan, MDClinical Associate Professor of

Rehabilitation MedicineNew York University School of

MedicineRusk Institute of Rehabilitation

Medicine New York, NY

Robert Allen Keith, PhDCasa Colina Hospital for

Rehabilitative MedicinePomona, CA

Sunny Kenowsky, DVMClinical InstructorDepartment of PsychiatryAssociate Director, Fisher

Alzheimer’s Disease ProgramNew York University School of

MedicineNew York, NY

Donald G. Kewman, PhD Clinical ProfessorDepartment of Physical Medicine

and RehabilitationUniversity of MichiganAnn Arbor, MI

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Ann M. Kremer, PhDMedical Social WorkerNeuroscience ProgramSt. Mary's Mercy Medical CenterGrand Rapids, MI

Edwin F. Kremer, PhD Senior Health PsychologistNeuroscience ProgramSt. Mary's Mercy Medical CenterGrand Rapids, MI

Marcia Lawton, PhDAssociate Professor (Retired)Department of Rehabilitation

CounselingSchool of Allied HealthVirginia Commonwealth

UniversityRichmond, VA

Barry S. Layton, PhD Assistant Professor of Physical

Medicine and RehabilitationCase Western Reserve UniversityCleveland, OH

Mathew H.M. Lee, MDChairman and Professor of

Rehabilitation MedicineNew York University School of

MedicineMedical DirectorRusk Institute of Rehabilitation

MedicineNew York, NY

Sicy H. Lee, MDAssistant Clinical Professor of

MedicineNew York University School of

MedicineHospital for Joint DiseasesNew York, NY

Patricia Kerman Lerner, MA DirectorSwallowing Disorders CenterNew York University Medical

Center New York, NY

Jerome Lowenstein, MDProfessor of Medicine Co-Director, Division of

NephrologyNew York University School of

MedicineNew York, NY

David G. Marrero, PhDProfessor of MedicineIndiana University School of

MedicineIndianapolis, IN

Diane Maydick-Youngberg, MS, RN, CWOCN

New York University MedicalCenter

New York, NY

Alex Moroz, MDAssistant Professor of

Rehabilitation MedicineAssociate Director of TrainingDepartment of Rehabilitation

MedicineNew York University School of

MedicineNew York, NY

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Richard J. Morris, PhDMeyerson Distinguished

Professor of Disability andRehabilitation

Director, School PsychologyProgram

University of Arizona, College ofEducation, Department ofSpecial Education,Rehabilitation, and SchoolPsychology

Tucson, AZ

Yvonne P. Morris, PhD Licensed Psychologist, Private

PracticeTucson, AZ

Kotresha Neelakantappa, MDClinical Assistant Professor of

MedicineNew York University School of

MedicineNew York, NY

Bruce G. Raphael, MDProfessor of Clinical MedicineNew York University School of

MedicineNew York, NY

Purva H. Rawal, MAPre-Doctoral StudentDivision of Clinical PsychologyNorthwestern University

Feinberg Medical School

Barry Reisberg, MDProfessor, Department of

PsychiatryClinical Director, Silberstein

Aging and Dementia ResearchCenter

Director, Fisher Alzheimer’sDisease Program

New York University School ofMedicine

New York, NY

Robert H. Remien, PhDClinical Psychologist and

Research ScientistHIV Center for Clinical and

Behavioral StudiesNew York State Psychiatric

Institute Columbia UniversityNew York, NY

Mariano J. Rey, MD Senior Associate Dean for

Student AffairsAssociate Professor of Medicine

and Physiology andNeuroscience

Director, Centers for HealthDisparities Research

New York University School ofMedicine

Director, Joan and Joel SmilowCardiac Rehabilitation andPrevention Center

Rusk Institute of RehabilitationMedicine

New York, NY

Steven C. Riggert, PhDFrazier Rehabilitation InstituteLouisville, KY

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Bruce P. Rosenthal, OD, FAAOAdjunct ProfessorDepartment of OphthalmologyMount Sinai HospitalandDistinguished ProfessorState University of New YorkChief, Low Vision ProgramThe Lighthouse InternationalNew York, NY

James Satriano, PhDDirector, HIV/AIDS ProgramsNew York State Office of Mental

HealthNew York, NY

Rose Mary ShawPsychology InternCleveland VA Medical Center Cleveland, OH

Sara A. Van LooyCornell UniversityIthaca, NY

Michael Weiner, MSWKaren Horney ClinicNew York, NY

Priscilla Bade White, MSDoctoral Student in School

PsychologyUniversity of Arizona, College of

Education, Department ofSpecial Education,Rehabilitation, and SchoolPsychology

Tucson, AZ

Nancy E. Wirth, MDPhysiatristAnn Arbor, MI

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This third edition of Medical Aspects of Disability: A Handbook for theRehabilitation Professional represents a significant update from the pre-vious editions. There is the addition of a new co-editor, Edwin F. Richter,a prominent board-certified physiatrist, academician, and researcher,who brings an important and necessary perspective to the content of thethird edition. Some of the chapters from the second edition have beencompletely rewritten, in some cases by new authors. Among the chap-ters from new authors are: “Neuromuscular Disorders” by LudmillaBronfin; “Ostomy Surgeries” by Les Gallo-Silver, Diane Maydick-Youngberg, and Michael Weiner; and “Burn Injuries” by Edwin F. Richter.Other chapters have been revised substantially and also include newco-authors. These updates reflect the dynamic nature of rehabilitationand medical science. New references represent advances in many aspectsof evaluation and treatment of disabling conditions, and new devel-opments in health care systems. The updated chapters on“Telerehabilitation—Solutions to Distant and International Care” byAndrew J. Haig and “The Computer Revolution and Assistive Technology”by Leonard Holmes reflect the continued convergence between clini-cal practice and modern technology. Consistent with the feedback from

Introduction to theThird Edition

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several teachers using the text in their classes, new chapters have againbeen included in the section on special topics: “Accreditation—A QualityFramework in the Consumer-Centric Era” by Brian J. Boon addressesthe importance of the accreditation process as a fundamental compo-nent of the quality assurance and improvement process. This new spe-cial chapter will serve as a useful review of this field for the current orfuture clinician. “Outcomes Measurement and Quality Improvementin an Acute Inpatient Rehabilitation Setting” by Ora Ezrachi addressesimportant developments in the process of evaluating the performanceof rehabilitation services. As medical care moves toward more use ofevidence-based practices, quantitative assessments of outcome data willbe increasingly important for clinical performance improvement andacademic purposes.

The editors are confident that this revised edition of Medical Aspectsof Disability will continue to present a very timely and comprehensiveoverview of important areas in rehabilitation service delivery. We arealso confident that this new edition will enable this textbook to con-tinue as a most useful resource in the classroom and for the practicingclinician.

Herbert H. Zaretsky, PhD

Acknowledgments

The editors also wish to acknowledge Gwen Treharne, Jane Ehlers, andPetrina Rodgers for their tireless efforts and invaluable assistance in thepreparation of this manuscript.

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Part IAn Introduction

to Key Topics and Issues

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1ComprehensiveRehabilitation:

Themes, Models, and Issues

Robert Allen Keith, PhD, and

Harriet Udin Aronow, PhD

Long-term demographic and epidemiological trends in indus-trial societies, including the United States, have changed the face ofhealth care. Communicable diseases, such as smallpox and measles,

no longer exact a toll on life. Modern medicine, better hygiene and liv-ing conditions, and improved nutrition have had a profound effect onhealth. Falling birth rates have changed age profiles so that older popu-lations make up an increasing proportion of the population. Not onlyare more people staying alive, they are living longer.

These two trends, more individuals staying alive and more livinglonger, have greatly increased chronic disease rates. A major share ofhealth care is now devoted to treating coronary heart disease, strokes,cancer, and arthritis, to name the more prominent chronic diseases.Individuals with catastrophic injuries, such as brain injury or spinalcord injury, now survive more frequently. It has been estimated thatthe prevalence of disability in all adults varies from 5.2% to 18.2%,depending on the underlying condition (DeJong et al., 2002). Chronicdiseases and injuries result in large numbers of people who requirespecialized services to regain lost functions: the role of comprehen-sive rehabilitation.

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The focus here is on medical rehabilitation and the remediation ofphysical and cognitive deficits. The model guiding such services, par-ticularly for hospital-based rehabilitation, has been the comprehensiveteam: physiatrists (physical medicine specialists), other physician spe-cialists, nurses, physical therapists, occupational therapists, psycholo-gists, speech and language specialists, social workers, recreationtherapists, and orthotists (individuals who design and make assistivedevices such as leg braces). With the advent of managed care, the casemanager has also been added to the team, an individual charged withidentifying and coordinating the most cost-effective treatment. Thepopulations served include individuals with strokes, brain injuries,spinal cord injuries, orthopedic disorders, neuromuscular diseases, andother such conditions. The rationale for such a broad array of servicesis that patients present a wide span of problems that require special-ized knowledge and treatment skills.

Although medical rehabilitation is a relatively small part of healthcare, it experienced considerable growth during the 1980s and early1990s, as did many sectors of health care. In 1985 there were 68 reha-bilitation hospitals and 386 rehabilitation units; by 2003 the numbershad grown to 214 hospitals and 1109 units (personal communication,American Medical Rehabilitation Providers Association, 2003). Thetally of outpatient programs is more difficult to determine because ofthe lack of organized statistics and also because of the diversity of serv-ices, many of which are not comprehensive and have specialized aims.There was considerable expansion, however, during the growth eramentioned. In the last few years the growth spurt in postacute serv-ices has come to a halt; the frenetic pace of mergers and acquisitionshas also slackened, principally because funds for such enterprises hasdried up. Services are increasingly in the hands of large corporations,however. HealthSouth Corporation, for example, owns and operatesover half of the free-standing rehabilitation hospitals (Wheatley, DeJong,& Sutton, 1998).

The provision of rehabilitation in skilled nursing facilities (SNFs),often called subacute rehabilitation, was one of the fastest growingservices in the mid-1990s. Costs are considerably lower than for com-prehensive hospital rehabilitation, although evidence of outcomes ismixed. The growth of SNF-based rehabilitation came to a halt withthe Balanced Budget Act of 1997 with a clampdown on Medicare pay-ments. Between the years 1998 and 2001, for example, several of thelargest chains filed for bankruptcy protection or went out of business(DeJong et al., 2002).

Rehabilitation shares in the increasingly chaotic status of U.S. healthcare. Both managed care and Medicare reimbursement for rehabilita-tion services have fallen. The comprehensive nature of care is being

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honored in the breach. Some disciplines, such as psychology, are beingexcluded as not essential. State budget crises have drastically reducedpayments for Medicaid and Departments of Rehabilitation. Despitethis bleak economic picture, the need is still expanding, as stated above,and the professional and personal rewards for working in the field stillremain.

THE ORIGINS OF REHABILITATION

The road to legitimacy has not been an easy one for rehabilitationmedicine, for either physicians in this specialty or other health pro-

fessionals in the field. An acquaintance with its origins helps to under-stand its current status and its response to changes in health care. Thehistory of medical rehabilitation is scattered through various journalsand presentations to professional societies. The best source of earlybeginnings is in Gritzer and Arluke’s 1985 volume The Making ofRehabilitation. Most of this account is taken from that work. The focusis on physiatry, physical therapy, and occupational therapy. Althoughother professions have made important contributions to medical reha-bilitation, these three have had the most prominent role in shaping theorigins of the field.

Physiatry

The term “physiatry” is a confusing one for those unacquaintedwith the physical medicine and rehabilitation specialty designation becauseit is close to psychiatry, a more widely known term. It was chosen from acombination of the Greek physis, meaning nature, and iatreia, healing.

The basis for specialization began before World War I, when a groupof physicians began using electrical stimulation and eventually addedthe modalities of hydrotherapy, heat, massage, and exercise. During thewar these physicians, who now called themselves physiotherapy physi-cians, joined other professionals in treating the consequences of injuries.After the conflict they returned to acute medicine.

World War II and the immediate postwar period brought significantchanges to most health care professions, including physical medicine. Eventhough there were heavy demands for services, physical therapy physicians(yet another name) did not initially establish a claim for special compe-tence. It remained for Howard Rusk, an internist outside physical medi-cine, to lay the groundwork for the modern field of physical medicine. Hebuilt a program on the use of convalescent time at an air force hospital thatbegan to feature physician training in rehabilitation methods.

With status as a medical specialty in 1946 came a more explicit

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recognition of the commitment to rehabilitation. The emphasis wasan important one because it marked a departure from the use of restas the prescribed treatment during convalescence in favor of recon-ditioning. That emphasis has remained and, if anything, has becomestronger in recent years with the general recognition of the impor-tance of fitness.

Physical medicine and rehabilitation remain one of the smallest spe-cialties in medicine, although the expansion of rehabilitation facilities hasstrengthened its position. The small number of physiatrists engaged inresearch is a matter of concern. The aggressive push by physical and occu-pational therapy for greater autonomy, particularly in independent prac-tice, is a challenge to physician control, although the physiatrist is stillacknowledged as the leader of the comprehensive treatment team.

Physical Therapy

The origins of physical therapy were also heavily tied to wartimeneeds. During World War I those individuals who had been orthopedicassistants were designated as reconstruction physiotherapy aides, andthey began to work with physical therapy physicians.

In 1921 former military aides and a few physicians formed whatwas soon called the American Physiotherapy Association. There thenfollowed a period of several years in which physiotherapy aides hadto battle to establish their legitimacy and independence. Relationswith medicine waxed and waned, with physicians insisting that aidescall themselves physiotherapy technicians to differentiate themselvesfrom physiotherapy physicians. By 1936 the American MedicalAssociation was accrediting physiotherapy schools. Doctors also con-trolled the American Registry of Physical Therapy, which restrictedthe opening of private offices by technicians. According to Gritzerand Arluke (1985), even though there was lack of autonomy, the fieldof physiotherapy benefited from this association with medicine byestablishing education and training standards that excluded thosewith poor preparation.

World War II did much to establish the status of modern physicaltherapy. When physicians acquired the title of physical medicine spe-cialists instead of physical therapy physicians, those individuals whohad been called aides or technicians were able to discard these termsfor the designation of physical therapist.

The later history of physical therapy shows this field to be in a verystrong position on the rehabilitation scene. In the early 1980s it brokethe domination of the American Medical Association in the accredita-tion of physical therapists and set up its own accrediting organization.The close relationship with physiatry no longer remains because most

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referrals to physical therapists now come from other medical specialties(Institute of Medicine, 1989). A significant number have chosen inde-pendent practice rather than an institutional setting. The perception ofthe importance of physical reconditioning and the expansion of reha-bilitation services have made physical therapy job growth greater thanthat of any other allied health occupation.

Occupational Therapy

Gritzer and Arluke (1985) observe that the origins of occupationaltherapy can be traced to the belief that activity and work can be thera-peutic, a connection first used for treating those with mental illness.Just prior to World War I, the first professional society for occupationaltherapy was formed. Early on, its members established the working prin-ciple that therapeutic activity should be physician-prescribed.

In the 1920s occupational therapy began to expand its base from men-tal institutions to include tuberculosis sanatoriums. The treatment ofindustrial accident injuries was also added to its domain. In the earlyyears of World War II, occupational therapy still had to fight the view ofits mission as diversional rather than therapeutic. Physical therapy physi-cians became interested in the potential of occupational therapy tobridge the gap between physical and vocational rehabilitation.

The postwar years have been marked by the push for greater auton-omy and also by the continuing struggle to convey to other professionalsand to the public just what it is that an occupational therapist does. Thedecision to opt for certification rather than licensure contributed tosome ambiguity of status. It was only in 1987, for example, that occu-pational therapy was able to bill separately under Medicare. The inclu-sion of occupational therapy with physical therapy (later to includespeech and language pathology) in the Medicare regulation mandating3 hours a day of therapy has helped to consolidate occupational ther-apy’s position in rehabilitation. Occupational therapists’ unique expert-ise in sensory and cognitive retraining ensures that they will remainimportant members of the treatment team.

All of the disciplines in rehabilitation have a vigorous scientific andpractice base by maintaining their own professional associations withscientific journals and web sites. An interdisciplinary association, theAmerican Congress of Rehabilitation Medicine, publishes one of theleading journals in the field, the Archives of Physical Medicine andRehabilitation. Another prominent journal, the American Journal ofPhysical Medicine and Rehabilitation, is published by the Association ofAcademic Physiatrists. Medical rehabilitation is also represented by atrade organization, the American Medical Rehabilitation ProvidersAssociation.

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COMPREHENSIVE REHABILITATIONOPERATIONS

Medical rehabilitation programs come in many forms,and they serve a variety of clients. In spite of this diversity, there

has been a common philosophy of treatment that holds that the com-plex problems of individuals with severe disability require the servicesof a team of specialists. No one profession has the knowledge andskills to address all the biological, psychological, functional, and envi-ronmental ramifications of chronic, severe disabling illnesses andinjuries.

Understanding rehabilitation operations requires a description ofthe kinds of rehabilitation facilities and programs, the caseloads thatthey serve, and some idea of how rehabilitation professionals divideup their labor and distribute themselves within the continuum ofrehabilitation services. The rapidly changing health care system hasresulted in the modification of some of the traditional forms of reha-bilitation.

The Continuum of Rehabilitation Care

Rehabilitation services exist in a continuum of post-acutecare. Typically applied after the onset of an acute episode of illness orinjury, post-acute care services include inpatient and outpatient reha-bilitation, chronic care, skilled nursing (distinct part) care, and homeand community-based health services. Rehabilitation services can beprescribed sequentially as levels of restorative care or singly as appro-priate pathways from office-based or hospital-based physician care andeven by self-referral.

For many years there was no defining mechanism for determiningthe number of rehabilitation programs in the United States.Consequently, there were no reasonable estimates of the number andkinds of rehabilitation programs in operation or of the populations theyserved. This uncertain identity obviously did not help the field’s questfor greater visibility. It also meant that rehabilitation was not oftenincluded in health care planning or policymaking.

With the advent of a prospective payment system for acute inpatientmedical and surgical hospital admissions beginning in 1983, the situa-tion changed dramatically. The prospective payment system was basedon diagnosis related groups (DRGs) within which patients had relativelysimilar costs for their acute hospital care. Inpatient medical rehabilita-tion units and hospitals were recognized to have patient populationsthat fell outside the typical distribution of costs of care. They were des-ignated as exempt from the use of DRGs, and a system for qualifying as

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an “exempt” unit or hospital was established. The qualifications included,among other provisions, a case mix with at least 75% of patients to fallwithin 10 diagnoses and a coordinated multidisciplinary treatment team(Health Care Financing Administration, 1982).

Alongside the rehabilitation hospitals and units there grew an impres-sive array of post-acute care services to accommodate the continuing careneeds of persons being discharged promptly (within the DRG limits)from acute care hospitals. There was enormous growth in distinct part(short term) units in skilled nursing facilities, home health care serv-ices, rehabilitation units and hospitals, and long-term chronic care hos-pitals (Liu, Gage, Harvell, Stevenson, & Brennan, 1999).

The Centers for Medicare and Medicaid Services (CMS—formallyHCFA) responded to this growth with alarm—and over time have adoptedsystems for regulating and rationalizing the use of resources within thecontinuum of post-acute services, including prospective payment byResource Utilization Groups (RUGs) in skilled facilities and impairment-based Case Mix Groups (CMGs) in acute licensed rehabilitation. In themeantime, rehabilitation services have been responding to changes inthe payment incentives with the prudent dual goals to maximize reha-bilitation outcomes for persons with disability while remaining fiscallysolvent. The current continuum of levels of rehabilitation care is dis-cussed in detail below.

Inpatient Acute Licensed Rehabilitation ProgramsInpatient programs receive most of their referrals from acute care hos-pitals. Because inpatients are still medically fragile and are severelyimpaired, close medical supervision and 24-hour nursing care are needed.All domains of health and function are assessed and monitored by theinterdisciplinary team. Treatment programs are usually multidiscipli-nary and intensive, that is, with a full schedule of therapy, because hos-pitalization is expensive.

Inpatient rehabilitation is provided in distinct units of acute hospi-tals, in freestanding acute licensed rehabilitation hospitals, and in affil-iated hospitals in health systems. With the trend for consolidation, thereare fewer freestanding rehabilitation hospitals today than 10 years ago,while increasing numbers of units and rehabilitation hospitals are ownedby chains.

Inpatient Skilled Licensed Rehabilitation ProgramsSkilled nursing facilities with distinct part Medicare beds afford patientsthe opportunity to have an extended period of recuperation with sometherapy as needed on a daily basis. SNF licensed beds providing reha-bilitation services are located as units (licensed as skilled nursing or tran-sitional care units) within acute licensed medical and surgical hospitals,

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within freestanding acute licensed rehabilitation hospitals, within free-standing long-term care facilities, and as freestanding skilled rehabili-tation hospitals.

With SNF licensing the frequency of medical supervision and level ofnurse staffing is reduced, and therefore this level of care can accommo-date patients with less acute medical needs. Skilled rehabilitation is tar-geted mostly to older post-acute patients who may not need, or be ableto tolerate, intensive programs of therapy. However, there have alsoemerged diagnostic specialty rehabilitation programs that are suited tothis level of care. For example, there are several programs throughout thenation that specialize in emergence from coma and ventilator depend-ent care housed in skilled licensed facilities. Highly regulated and depend-ent on public funding, these programs are changing rapidly as paymentpolicies are reformulated at CMS and the private insurance industry fol-lows suit.

There is some controversy about the effectiveness of SNF-based reha-bilitation in comparison to hospital-based programs. In examining thesetwo settings, Kramer and colleagues (1997) found an advantage of acuterehabilitation for patients with strokes but not for those with hip frac-tures.

Comprehensive Day Treatment ProgramsAlthough more commonly used for psychiatric and substance abusetreatment, comprehensive day treatment programs are also availablefor persons with physical and cognitive disabilities. Like their mentalhealth counterparts, the comprehensive day rehabilitation programshave the goal of preventing long-term institutionalization while pro-viding a quality daily program of activities. Some day rehabilitation pro-grams provide restorative services and are geared toward therapeuticgoals, a defined length of stay, and discharge to a more independentcommunity life. The therapeutic program is intensive and targeted forpersons not requiring overnight care, but not able to care for themselvesat home (e.g., persons with acquired brain injury). The other main typeof comprehensive day treatment program is geared more to long-termcare in a maintenance model. This level of care may be distinguishedfrom Adult Day Care for older persons with dementia by its greater med-ical supervision and ability to take clients who require daily nursingcare and therapies.

Outpatient Rehabilitation ProgramsOutpatient rehabilitation care can be provided in a wide variety of set-tings and programmatic models—ranging from single services providedin physician offices to licensed multidisciplinary comprehensive pro-grams. In 2000 there were a total of 516 licensed Comprehensive

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Outpatient Rehabilitation Facilities (CORFs) receiving reimbursementfor patient care from the CMS. While relatively popular in the 1980s,currently there is great regional variation in the use of CORFs. Floridahas the largest number of CORFS, 181, while California has just 14 (CMS,2002). Comprehensive multidisciplinary outpatient services are alsoassociated with acute inpatient rehabilitation facilities, providing fol-low-up therapies for discharged inpatients, and as post-acute commu-nity-based day programs for diagnoses that benefit from intensivemultidisciplinary therapies in a more home-like setting (e.g., traumaticand acquired brain injury).

Pediatric rehabilitation is most commonly provided in outpatientsettings. Increasingly, payment policies favor providing therapy to chil-dren in more ecologically appropriate settings, such as in the home withfamily members or in the classroom with teachers and other studentspresent. A reverse trend, moving physician specialty clinics out of com-munity settings and into outpatient rehabilitation settings, may also beecologically appropriate for persons with disabling chronic diseases,such as arthritis and neurological conditions.

There are a host of care settings in which single discipline therapiesare provided, including industrial and occupational health clinics, physi-cians’ offices, and freestanding outpatient therapy clinics. Again, a recentfunding decision by CMS (July 1, 2003) to limit total annual reimburse-ment for physical therapy to $1,950 and occupational therapy to thesame amount may precipitate rapid and profound changes in the settingsin which these outpatient therapies are delivered.

In addition to settings in which rehabilitation care is provided andfunded by insurance, there are a growing number of settings in whichtherapeutic services are offered and paid for out of pocket by the con-sumer or in some contractual manner with an existing health careprovider. These settings include sports and fitness centers that offertherapeutic classes or individualized programs, community centers,clubs, and resorts. As more “baby-boomers” age into middle and olderyears, we can expect to see the demand for informal and self-directedrehabilitation programs to increase.

Residential Rehabilitation ProgramsResidential rehabilitation and habilitation programs provide extendedtherapeutic services for persons with chronic or life-long disabilities.Transitional Living programs, typically provided at the termination ofacute rehabilitation treatment or after an unsuccessful re-integrationinto home and community life after serious injury or illness, have astheir common goal successful community re-entry and participationin home and community activities. Similar services may be offered inlong-term supervised and semi-independent living programs to provide

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residential supports and periodic restorative care for persons living andaging with disabilities.

Home and Community ProgramsA final level of care in the rehabilitation continuum is provided in thehome and community setting. This level of rehabilitation care has seena recent increase in demand with the general aging of the population.Physical therapists, occupational therapists, and speech pathologistshave joined the home care team for patients after orthopedic surgeriesfor major joint replacements, strokes, and for a host of older patients whosuffer from debilitation after an episode of acute hospitalization. On theother side of the age continuum, increasing interest is being expressedfor providing pediatric rehabilitation services in the school and com-munity within the social network of family and school community. Justas this setting makes more sense for children, persons receiving reha-bilitation for traumatic brain injuries may be best served in the famil-iar home and community settings where they will have to perform theirnewly restored behaviors.

Populations Served

Just as lack of information about the definition of rehabilitationfacilities hampered the development of medical rehabilitation, so too hasa scarcity of caseload information been a hindrance to the understandingand rational distribution of rehabilitation resources to specific groupsof persons living with disabilities.

The rehabilitation industry has begun to keep and publish statisticson the use of rehabilitation services. One of the oldest and largest effortsto maintain a minimum set of common data on patients dischargedfrom comprehensive rehabilitation services has been managed by theState University of New York at Buffalo. The Uniform Data System forMedical Rehabilitation (UDSmr) 10th annual report described almost300,000 rehabilitation patients discharged from 676 participating facil-ities in 1999 (Deutsch, Fielder, Granger, & Russell, 2002). The reportshows that orthopedic conditions, primarily lower extremity fracture andjoint replacement, comprised the largest group of admissions (30%) withstroke the next largest (23%). Lengths of stay have plummeted over thepast 10 years, from an average of 28 days in 1990 to 16 days in 1999.

The situation in the rehabilitation industry has changed dramati-cally since 1999, with the implementation of the prospective paymentsystem (PPS) for rehabilitation in 2001. More recent data, drawn froma newer data system, based on the CMS mandated InpatientRehabilitation Facility–Patient Assessment Instrument (IRF-PAI), reflectthese current trends.

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In 1999, the American Medical Rehabilitation Providers Association(AMRPA) developed an electronic data system, eRehabdata, for partici-pating AMRPA facilities to use to model the effects of prospective pay-ment system. Volunteer facilities submitted UDSmr data, billingabstracts, and Medicare Cost Reports to eRehabdata to produce costbenchmarking data and allow the facilities to model the costs and out-comes of patients under varying assumptions of payment and servicedelivery (http://www.erehabdata.com). The system received data fromover 117,000 patients discharged in 2002. It has been expanded to accom-modate new IRF-PAI billing, standard, and ORYX outcome data reportsand other patient outcome analyses.

Program Operations

Although rehabilitation programs (inpatient and outpatient)do not all conduct their operations in the same way, they have manyprocesses in common because of the nature of the tasks involved andthe position of rehabilitation in the continuum of health care services.

Referral and ScreeningDetermining appropriateness of the individual for comprehensive med-ical rehabilitation occurs before admission (at the time of referral andagain at pre-admission screening), after admission (in initial evalua-tion), and during treatment (in monitoring progress and continuedappropriateness). This repeated process is intended to contain costs andto ensure the proper fit between patients and services. The process isnot exclusively within the rehabilitation provider’s control, however,which is one of the reasons the rehabilitation industry expends resourceseducating referral sources and regulators about the appropriate use ofrehabilitation services. Referral and screening decisions, however, arenot clear cut. Decisions may vary systematically by region and availableresources, and must be factored into a multidimensional assessment ofpersonal, environmental, and social resources that affect the appropri-ateness of one level of care over another.

Diagnosis and AssessmentDiagnosis commonly refers to the process of determining the status ofdisease or complaint and assigning the remedy. In rehabilitation, assess-ment is concerned with detailing the functional capacities of the patient,specifying those that are likely to benefit from treatment. It is at thisfunctional level that the specific array of treatments are paired andsequenced with the individual patient or client’s pattern of deficits.

It is ultimately a physician who makes a diagnosis and authorizesthe treatment for a patient in a comprehensive medical rehabilitation

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program. Rehabilitation physicians have traditionally played a leader-ship role in the treatment team, organizing the information gatheredfrom assessments and formulating a plan with the expert input of mul-tiple clinical disciplines that make up the treatment team.

Team TreatmentIn comprehensive, multidisciplinary rehabilitation settings, the assess-ment process is the first demanding test of the treatment team’s abilityto coordinate the scheduling of time for various assessments and tocommunicate its findings. It is usually at the initial team conferencethat information about the patient is exchanged and evaluated, culmi-nating in a treatment plan that anticipates the patient’s progress throughthe treatment stages.

The comprehensive multidisciplinary team model of treatment deliv-ery served to distinguish rehabilitation from the rest of health care formany years. Reviews of research concluded that coordinated interdisci-plinary team care was superior to general medical care or uncoordinatedrehabilitation (Keith, 1991; Ottenbacher, & Jannell, 1993; Teasell, Foley,Bhogal, & Speechley, 2003). But research on team care outcomes is scarce,and results of some studies and reviews have been contradictory.

As mentioned earlier, there are serious challenges to the team con-cept. Using a full spectrum of specialists is expensive, particularly for aninpatient program. The prevailing philosophy among professions is stillfor team care. However, in recent years its form has been modified. Theteam has been attenuated in some instances by accommodating a con-tinuum of levels of care with varying levels of therapy intensity andmedical and nursing care. Acute inpatient rehabilitation is still governedby the multidisciplinary team. Skilled rehabilitation care or in-homeservices may reduce the team to its bare necessities to address specificfunctional and medical issues. Outpatient rehabilitation is frequentlydelivered by a single discipline. However, clinicians regularly providefeedback and recommendations for continued care to both the primarycare physician and the patient.

Documentation, Progress Monitoring, and CommunicationRehabilitation is highly regulated by the government, voluntary accred-itation organizations, and insurance payers. Like other tertiary careproviders, rehabilitation sits downstream in a continuum of health careservices and is dependent on referral sources for its flow of patients.Furthermore, it is responsible for handing patients back into the con-tinuum of ongoing primary and specialty care services. In someinstances, where managed care contracts put upstream providers atfinancial risk for tertiary services, rehabilitation providers are directlydependent on their referral sources for payment for services provided.

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In this position of managing patient care both up- and downstream,documentation, monitoring patient progress, and communicationbecome of paramount importance for both the quality of patient careand the financial success of rehabilitation providers.

As a result of these forces, rehabilitation providers spend an increas-ing amount of resources documenting patient’s progress and what wasdone for the patient during the daily treatments. Some of this is neces-sary for clinical management, judging patient gains in relation to thetreatment plan, and as a daily communication tool among the many cli-nicians who treat rehabilitation patients on a daily basis. But much doc-umentation serves the benefit of third party payers, accreditation andregulatory standards that require detailed treatment justifications anddocumentation in permanent records.

Although much information is exchanged informally among teammembers as they go about day-to-day duties, the team conference is theplace where formal communication is the focus. In this setting, reportsfrom members are heard and information integrated and evaluated,with conclusions about progress and the direction of the therapeuticplan. Many teams choose to include the patient and family members insuch deliberations at some point, because they are an integral part ofthe rehabilitation process and play an important role in understandingand carrying out the treatment plan both within the rehabilitation treat-ment setting and after returning to the community and the continuingnetwork of primary and specialty health care providers.

Discharge PlanningWhen patients near the goals set in the treatment plan, or plateau intheir progress towards those goals, the focus shifts more toward the set-ting in which the patients will continue to live. The plan may involve con-tinued rehabilitation, long-term care, and reintegration into communitylife. The members of the rehabilitation team must understand as com-pletely as possible the physical and social environment and create a dis-charge plan that accommodates the abilities and needs of patients andtheir support system. This is a complicated process, fraught with phys-ical and social obstacles. With the trend for shortening inpatient lengthof stay, discharge planning must include preparing patients and familyto manage home programs of exercise, unresolved medical and nursingissues, and an array of continuum of care services that the patient maybe recommended to use.

Going forward in time, it is difficult to predict exactly where patientswith serious physical impairments and disabilities will be receiving theirrehabilitation services. It is likely that there will always be a continuumof post-acute rehabilitation settings. How these resources are allocatedwill be determined in part by policy and financial incentives, and partly

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by the force of evidence of the most effective application of the reha-bilitation model.

RESEARCH AND EVALUATION ISSUES

Research in health care has two major functions: to test theeffectiveness of current clinical practices and to identify promis-

ing new directions of assessment and treatment. Rehabilitation has anadded dimension in its research activities, that of program evaluation.It is one of the few health care services that requires program evaluationfor accreditation. The concern with program objectives, robust meas-ures, and accountability has positioned the field to deal with the pre-occupation with outcomes management more easily than many othersectors of health care. Evaluation addresses the social utility of a result,one step beyond the usual research orientation. It must be added, how-ever, that evaluation has primarily influenced program managementwith few contributions to the scientific literature.

Theoretical and Conceptual Issues

Most fields with a heavy practice orientation, such as medicalrehabilitation, devote relatively little effort to examining the theoreti-cal assumptions under which they operate or formulating new theo-ries. As a social scientist observed many years ago, however, there isnothing so practical as a good theory. Theories are the blueprints to helpunderstand what goes on in rehabilitation and to chart research direc-tions for the future.

Disablement TheoryOne of the earliest theories in rehabilitation, and the most familiar, con-cerns the consequences of disease and injury, that is, disablement. TheWorld Health Organization (WHO) concepts of impairment, disability,and handicap (WHO, 1980) have been widely used in practice, research,and social policy. There have been a number of modifications to thistheory, but its original form has remained the most influential.Impairments are deficiencies at the organ level, for example, paralysisresulting in loss of hand function. Disability is the performance deficitfrom such an injury, the inability to complete a meaningful task, suchas dial a telephone. Finally, handicaps are losses as a result of social rolefunctioning, the result of personal and social interactions, such as theinability to remain employed as a result of disability and social prac-tices regarding who is employable.

There have been obvious deficiencies in this classification and for

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the past 10 years WHO officials have collaborated with health care inves-tigators and practitioners in several countries on a revision, theInternational Classification of Functioning, Disability, and Health (ICF)(WHO, 2001). The new version incorporates some of the concerns ofadvocates of empowerment of the disabled by using more neutral terms.It has also been influenced by views of health status and quality of life(to be discussed later in this chapter). The term impairment has beenretained, now to include problems in body structure or function.Disability has been discarded in favor of activities, which are an indi-vidual’s performance of tasks or activities. Handicap has been losingfavor as a term because of its pejorative connotation and has beenreplaced by participation, which is an individual’s involvement in lifesituations, taking into account health conditions, body structures andfunctions, activities, and contextual factors. A new addition is contex-tual factors, which include environmental factors (physical, social, andattitudinal environments) and personal factors (gender, age, fitness,habits, etc.).

The ICF is considerably more ambitious than its predecessor and isintended to address health conditions for all populations, not just thedisabled. Environmental factors, although important, are very difficultto catalog, including, for example, a span from physical geography tosocial support and relationships. Producing a coherent scheme to phe-nomena that vary widely by culture or social class is a daunting task.The ICF will go through a lengthy testing period to see how well theclassifications can be used. A concise account of the development ofthe ICF can be found in Gray and Hendershot (2000), both of whomparticipated in the evolution of the scheme.

Treatment TheoryThe drive to identify the most cost-effective treatment methods hasbrought about the realization that there must be a better understand-ing of the rationale of treatment. Most outcome research has notincluded detailed description of what treatment was given, so there hasbeen little empirical basis on which to identify the elements of inter-vention that have the greatest effects.

The implicit assumption behind most rehabilitation is that greaterexposure to treatment results in greater gains, but there is inconsis-tent evidence to support this assumption (Keith, 1997). A major para-dox has been that discharge indicators for some conditions haveremained at the same levels in the face of rapidly dropping lengths ofstay. For example, over a 10-year period the length of stay for stroke inthe UDS dropped from 32 days to 20 days, a decrease of 37%. At thesame time, average admission and discharge FIM scores changed verylittle, as did the percentage of patients discharged home (Granger &

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Hamilton, 1992; Fiedler, Granger, & Post, 2000). An important issue iswhat strategies therapists have used to deliver treatment in the face ofsuch drastic reductions.

One of the goals of the Research and Training Center for MeasuringRehabilitation Outcomes, situated at Boston University, is to studydetailed treatment methods and patient characteristics of individualswith stroke in eight facilities to determine how and to what degree var-ious treatment components contribute to outcomes (Haley & Jette,2000). A major first step is to begin a taxonomy of treatments to clas-sify interventions.

Treatment strength has been advanced as a key ingredient in classi-fying and understanding the components of rehabilitation treatment(Keith, 1997). The formulations involved, taken from concepts in med-icine and pharmacology and also used in program evaluation in thesocial sciences, include purity, specificity, dose, intensity, duration, tim-ing, and the treaters and their organization. Review of both length of stayand intensity did not find consistent relations between greater gainsand more therapy, although research designs varied greatly in explana-tory power. Identifying the essential elements of comprehensive reha-bilitation is made even more difficult, of course, with the use of theinterdisciplinary team. Not only the effects of each disciplinary mem-ber must be studied, but also the manner in which the team is organizedand deployed.

Measurement Issues

Although measurement has always had a central role in reha-bilitation, the increased use of health status and health-related quality-of-life instruments has considerably widened its scope. In addition,technical developments in test construction and administration havebrought new measurement directions.

Data Systems for Medical RehabilitationUniform Data System . The greatest influence on patient assess-ment and data collection has been the Uniform Data System for MedicalRehabilitation (UDS), already mentioned. The system was designed withthe recognition of the importance of having data elements and a func-tional status measure that would be used uniformly throughout a largenumber of facilities. The Functional Independence Measure (FIM), whichwas developed for the system, has become the most widely used func-tional status instrument in rehabilitation and has been used in dozensof research investigations. It is also a key ingredient in Medicare’s cur-rent prospective payment system.

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eRehabData . The American Medical Rehabilitation ProvidersAssociation, responding to the need for better financial data to accom-pany patient information, developed eRehabData, also already men-tioned. It combines data elements from the UDS with detailed financialdata for outcomes that are tailored for management.

Outpatient Data Systems. The two largest data services for out-patients, LifeWare (Granger, 1999) and FOTO (Focus on TherapeuticOutcomes) (Dobrzykowski & Nance, 1997), both have significant fol-lowing, although neither has imposed the uniformity on outpatientservices as has the UDS for hospitals. LifeWare is the evolution of sev-eral versions of brief outpatient assessment instruments developed byGranger and colleagues. There are currently versions for musculoskele-tal, neurologic, and “complex” populations. It includes an amalgama-tion of physical skills related to everyday functioning, pain control,affect, well-being, and more specific items for various conditions. TheFOTO system was created for providers of outpatient orthopedic reha-bilitation, primarily physical therapy, but has evolved into a system thatnow includes forms for musculoskeletal, neuromuscular, cardiopul-monary, wound care, industrial, and pediatric patients. Patients answerquestions from a pool of items in a computer-assisted testing format.

Health Status, Quality of Life, and Health-Related Quality of Life

Health status measures are beginning to have a significant impacton the way rehabilitation outcomes are formulated and measured.Although rehabilitation, particularly inpatient treatment, has alwaysregarded itself as providing comprehensive care, its outcome measureshave had a narrow focus. The emphasis has been on functional statusskills of the most basic kind, such as self-care and mobility. Generic healthstatus instruments have a much broader scope. The SF-36, for example,the most widely used of such measures, has eight scales devoted to phys-ical functioning, role limitations because of physical health problems,bodily pain, social functioning, general mental health, role limitationsbecause of emotional problems, vitality (energy/fatigue), and generalhealth perceptions (Ware & Sherbourne, 1992). Originally developed forhealth policy research with large populations, health status measures usea self-report questionnaire format, a significant departure from the tra-dition in rehabilitation of clinician observation and judgment of patientperformance. Because of their generic nature, such scales can be usedacross clinical populations with a variety of diagnostic problems. Anexcellent review of the use of health status measures in disability out-comes research can be found in Andresen and Meyers (2000).

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Quality of life (QOL) has been of interest in the social sciences formany years, although serious consideration by rehabilitation has beenmore recent as shown by a review by Dijkers (1997) and two supplementson the topic in the Archives of Physical Medicine and Rehabilitation(Tulsky, 2002). Rehabilitation medicine has traditionally been concernedwith the remediation of functional deficits. Several forces in health careand in society at large have converged, however, to demand that atten-tion be paid to the effects of treatment on everyday life as a legitimateaim of care. The mission of rehabilitation then becomes not only deficitreduction but life enhancement. Quality of life becomes a measure-ment issue, although there is no consensus about how it should be con-ceptualized or measured. Some authors have equated QOL with varioushealth status scales, but no one instrument encompasses the domainsinvolved.

Quality of life refers not only to one’s satisfaction with life but alsoto a broad array of circumstances, such as housing, employment, socialconditions, and the like, factors not related to health and for whichhealth care providers are not responsible. To narrow the concept, theterm health-related quality of life (HRQOL) has been devised. Patrickand Erickson (1993, p. 22) have defined HRQOL as “. . . the value assignedto duration of life as modified by the impairments, functional states,perceptions, and social opportunities that are influenced by disease,injury, treatment, or policy.” Even with the narrower focus, there is noagreement about measuring HRQOL. Some generic measures, such asthe SF-36 or the Sickness Impact Profile (Bergner, Bobbitt, Carter, &Gilson, 1981), sample several domains of activity and function that areaffected by health. Others are more targeted, including disease-specificmeasures, such those concerning arthritis or spinal cord injury, andcondition-specific instruments, such as those dealing with specific symp-toms such as depression or pain. Authors often label measures at assess-ing HRQOL without providing any rationale. All these measures areself-report questionnaires with the assumption that the perceptionsand judgments of patients are important in assessment. There is oftenno feasible alternative to self-report to determine the effect of treat-ment on the patient’s ability to carry on a variety of life activities out-side the clinical setting.

Although HRQOL measures are an attractive addition to rehabilita-tion’s array of measures, as their use increases, many problems havebeen identified. Several authors have pointed out that health statusmeasures often equate health with lack of disability (Hays, Hahn, &Marshall, 2002; Tate, Kalpakjian, & Forchheimer, 2002). For example,the SF-36 asks if work or other regular activities have been affected byphysical health. An individual with spinal cord injury might have diffi-culty answering because his or her general state of health might be alright

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in spite of paralysis. Another problem is the often lack of relationshipbetween an individual’s objective condition and his or her perceptionof quality of life or satisfaction with life (Dijkers, 1997). It is also evi-dent that individuals may recalibrate their expectations over timewith fewer options for activities still bringing satisfaction with life(Schwartz & Sprangers, 2000). Tate and colleagues (2002) observe thatthis dynamic change in framework may threaten the foundations ofour assumptions about the use of HRQOL measures to evaluate healthcare interventions.

The use of health status and HRQOL measures is rapidly increasingin rehabilitation. Their breadth of perspective and use of the patient’spoint of view are an important addition to outcome measures. Thereare many conceptual and methodological problems in use, however,that have to be addressed if these instruments are to have maximumutility for rehabilitation.

RESEARCH AND EVALUATION ISSUES

Outcomes Research

Determining what strategies will improve health while adher-ing to cost restraints is a continuing preoccupation of health care.Outcomes research is the term used to describe the search for cost-effec-tive interventions. For outcomes research to have an impact on reduc-ing costs and improving the quality of care, two conditions must bemet. The research must be designed with sufficiently powerful researchdesigns and measures to provide credible results. And second, such con-clusions must be recognized and applied by health care providers andpayers. Despite the resources devoted to outcomes research, there isscant evidence that the results have had much direct effect on healthcare policies and practices (Stryer, Tunis, Hubbard, & Clancy, 2000).This does not mean that outcomes research should be abandoned; onlythat expectations about its impact should be modest. A research topicthat has had insufficient exploration is the extent to which managedcare organizations and other funders pay attention to outcomes in theirreimbursement policies. A useful discussion of the evidence needed fordisability outcomes research can be found in Jette and Keysor (2002).

A major shift is occurring throughout health care in the goals of out-comes research, from a focus on clinical outcomes defined by profes-sionals, to including the improvement of health and the patient’sperspective on health (also discussed in the section on measurement).While the identification of effective interventions is important, admin-

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istrators of managed care recognize that a major way to reduce healthcare costs is to encourage healthier life styles and reduce utilization ofservices. Health status and health-related quality-of-life measures arethe major means to assess treatment outcomes related to these goals.

Commonly cited rehabilitation outcomes have included dischargeto a home setting, improved functional status, reduction in the needfor assistance or supervision, reduction of treatment costs, and improve-ment in productive activity (Keith, 1995). This list has been seen as nar-row in light of the emphasis on patient perspectives and so additionssuch as satisfaction with services and treatment outcomes, improvedsense of well-being, and improved life-satisfaction and other aspects ofquality of life have been suggested. Granger (1998) has noted thatimprovements in functioning, the traditional aim of rehabilitation,must be demonstrated not only in the clinical setting but also in day-to-day activities. Although there is general agreement about the goals ofrehabilitation, there is little consensus, beyond a core of basic indicators,about how such goals should be defined or measured.

Evidence-based Practice and Randomized Clinical Trials

With rising health care costs throughout the industrialized worldhas come the recognition of the importance of basing clinical proce-dures on firm scientific grounds. This has led to collaborative efforts tosearch the medical literature and establish uniform standards for judg-ing the adequacy of research. The Cochrane Library, which archives theresults of randomized clinical trials, is one example of this cooperation(http://www.cochrane.org/). In the U.S. the Agency for Health Care Policyand Research sponsored various centers to determine the best treat-ment procedures for many common medical conditions. One of themost well-known projects relevant to rehabilitation is clinical practiceguidelines for poststroke rehabilitation (Gresham et al., 1995). This agency,now the Agency for Healthcare Research and Quality, funds Evidence-Based Practice Centers which develop evidence reports and technologyassessments based on syntheses of the scientific literature. The OregonHealth and Science University, for example, has completed an exhaus-tive review of the literature on the effectiveness of interventions torehabilitate individuals with traumatic brain injury (http://www.ahcpr.gov/).

Randomized clinical trials (RCTs) have long been recognized as themost powerful means of investigating research issues. In this researchdesign subjects are randomly assigned to experimental or control groups,conditions for both groups are explicitly described, and the ultimatecomparison has greater validity than other designs. For many years it

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was assumed that this methodology was most appropriate for drug tri-als or basic research. RCTs are expensive to conduct and there are oftenethical issues about withholding treatment for a control group. In reha-bilitation there is the added complication that most treatment is deliv-ered by a team, which makes it difficult to identify which factors areresponsible for improvement.

In spite of the barriers to implementation, there has been consider-able interest in RCTs in rehabilitation; a recent supplement to theAmerican Journal of Physical Medicine and Rehabilitation was devotedto the subject (Millis & Johnston, 2003). The perception has been thatthere have been few such applications in rehabilitation, but a reviewof the literature revealed a surprising 4,874 publications using RCTs(Johnston, 2003). Nearly two-thirds of the research was devoted to inves-tigating pain, particularly back, neck, or joint pain. Only 10% involvedpatients with stroke; less than 4% included brain injury or spinal cordinjury. So diagnoses of particular interest to medical rehabilitation havenot had much study with RCTs.

Considerations in the deployment of RCTs will lead to better researchwhether or not that design is used. Whyte (2003) has outlined the impor-tant factors. First of all, there needs to be accurate characterization ofresearch participants beyond the usual age and sex data. Second, treat-ment needs to be specified with sufficient detail to be able to identifywhat it is that affects the patient. It helps to have a treatment theory toguide formulations. Third, the outcomes of treatment must be meas-ured in a reliable and valid manner with indexes that have clinical andsocial value.

Constraint-Induced Movement Therapy

One of the most frustrating experiences of hemiplegia, whetherfrom stroke or some other central nervous system damage, is the inabil-ity to use the affected upper extremity. Rehabilitation has commonlyfocused on lower limb restoration because of the greater gains, althoughpatients value upper limb function more. Constraint-induced move-ment therapy (CIMT) is a promising method for improving upper armfunction, reversing the assumption that there is usually little improve-ment. Edward Taub, a neuropsychologist at the University of Alabama,and colleagues initially worked on the training of monkeys with a deaf-ferented limb, restricting use of the intact limb and using behavioralshaping techniques with very small steps to overcome what has beencalled learned nonuse (Taub, Crago, & Uswatte, 1998). In this state, thesubject has aversive experiences in attempts to use the paretic limb andis positively reinforced for compensating with the intact limb. Taubwas then able to apply the techniques from such research to chronic

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stroke patients with an upper extremity hemiparesis (Taub et al., 1993).The investigators found that individuals who agreed to wear a sling ontheir unaffected arm for 90% of waking hours for 14 days significantlyimproved on both laboratory tests and real-life skills. Other investiga-tors have been able to duplicate the results of this research team.

COMPREHENSIVE REHABILITATION: PRESENT AND FUTURE

Current Status

In previous editions of this chapter, mention was made of twopotentially important directions of government policy regarding thedisabled. Disability in America (Pope & Tarlov, 1991) was an Institute ofMedicine report on the prevention of disability, reviewing the scope ofdisability and a new model for the disabling process from a social andpublic health perspective. The second publication, Enabling America(Brandt & Pope, 1997), was also an Institute of Medicine report, againreviewing conceptual models and examining research on assessment,health services research, the status of science and engineering, and therole of Federal research programs. Both of these works showed a livelyinterest in addressing the major problems of the disabled. In recentyears, however, there have been few government policy initiativesregarding the disabled or rehabilitation The status of the economy andof health care has precluded many bold ventures.

For the last several years a dominant theme in rehabilitation hasbeen the intense commercialization of the field which resulted in anexplosion of expansion and reorganization. As in all of health care, thepressures to contain costs have continued the trend toward decreas-ing professional control over services. In addition, staff are asked toincrease their work loads; individuals with lower qualifications arebeing used in treatment. Patients are often treated at a lower level ofcare than in previous practices. Many patients with strokes, for exam-ple, are now channeled to skilled nursing facilities for rehabilitationrather than to a hospital. It remains to be seen how well this situationserves health care needs.

Although the frenetic pace of acquisitions and mergers has subsided,the aftermath of overexpansion and instability continues, particularlywith some of the large chains. A positive consequence of the restruc-turing has been an increase in the variety of facilities in which rehabil-itation is carried on. Twenty years ago there were a few traditionalsettings that supported rehabilitation: inpatient hospitals, outpatient

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clinics, and private offices. Now there are organizations of physical,occupational, and speech therapists that do home visits; satellite clinicsof hospitals; sports medicine facilities; and a variety of other organiza-tional formats.

THE FUTURE

The delivery of appropriate rehabilitation services to those whoneed and can profit from treatment rests, to a considerable extent,

on reforms of the U.S. health care system. Despite heroic efforts to bringdown costs through managed care and decreased payment by govern-ment agencies, the current trend, which threatens to continue, is forincreasing expenditures for health care. Some 41 million individuals arewithout health insurance and those who are insured must struggle tomaintain coverage. Physicians are limiting participation in governmentprograms because of inadequate payment. The future of rehabilitationand of health care in general depends on changes.

On a brighter note, there are a number of developments that have fur-thered the rehabilitation cause. Keeping fit has become a national pre-occupation, although the continuing increase in obesity shows that thepreoccupation is not always translated into action. The distinctionbetween exercise for fitness and for recovery during rehabilitation hasbecome blurred, as it should be. Regular exercise is a cornerstone ofphysical medicine and is a key to the success of restorative treatment.Community hospitals are offering exercise classes that may target spe-cific medical conditions. Some rehabilitation hospitals have formedpartnerships with existing commercial health clubs to offer rehabilita-tion services within such clubs. Automobile manufacturers have addedonsite rehabilitation centers for employees who are injured. In addi-tion, many more individuals not previously disabled are becomingacquainted with rehabilitation routines after having arthroscopic sur-gery, hip replacements, or other types of surgery. Rehabilitation con-cepts and procedures are being used widely outside of traditionaltreatment facilities.

Advances in treatment and adaptive devices are occurring at a rapidpace because of miniaturization and digitalization of equipment. Forexample, wheelchairs had come in standard sizes, not all of which coin-cided with patient requirements. Now it is possible to build a wheel-chair to fit individual specifications. For certain repetitive exercises,robots have been designed that take the patient through the movementsinvolved and free up therapists’ time. A major development will be theacceleration of innovative information technology with automatedmedical records, physicians having access to patients’ records even at

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remote locations, and better organized systems of outcomes manage-ment. The Internet, already an important information source, will con-tinue to grow in importance for accessing research data bases, exchangeof data, teaching, and communication between facilities.

Although comprehensive rehabilitation has been diluted in recentyears because of cost cutting, it is still the most appropriate model ofcare. If restorative treatment is to be effective, it is necessary to con-sider the patient’s life in totality, not just the immediate physical deficits.Otherwise the gains realized during treatment may not endure oncethe patient returns home. And, as stated earlier, the mission of reha-bilitation is to benefit the patient’s everyday existence. Funders of caremay find that if gains are not maintained, cost savings become illu-sory. Formulations about disablement, such as the InternationalClassification of Functioning, Disability and Health (WHO, 2001),endorsed by the international health care community, have broadenedthe view of what health care should be concerned with. Likewise, theincreasing use of health status and quality of life measures as legiti-mate outcomes also contributes to a wider perspective. The aging pop-ulations of all industrial nations, including the U.S., are producinginexorable pressures for restorative services. Comprehensive rehabil-itation will prevail.

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