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, psychologic, 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 requiring 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 injuries, multiple injuries 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 musculoskeletal 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 injury was a natural consequence of the merger of medical and allied interests, knowledge, and technologies developed during and after World War II. Experience with the early care and rehabilitation of persons with war injuries led to a new emphasis on the establishment of multidisciplinary centers like the spinal cord injury 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, orthotics and prosthetics, vocational counseling, and rehabilitation engineering. 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 amputations, prosthetics, and management of multiple musculoskeletal injuries and neurotrauma. Reconstructive surgical 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, vocational, and behavioral techniques were developed. Peer counseling of successfully rehabilitated persons promoted the use of restored functions in daily life, and that led to independent 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, psychologic, and social responses to paralysis and movement disorders, disfigurement, and loss of body parts are controllable to a remarkable extent. Although limited resources for clinical programs have been provided through private and publicly supported efforts, parallel research and educational resources for the development and dissemination 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 unserved persons who could benefit.

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 scientists, engineers, clinicians, and behavioral and social scientists to solve problems in and evaluate postinjury and rehabilitation care. Many important research questions 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 technologies 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 needless 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 federal governments.

Among persons severely disabled from all causes, including injury, 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 Help to brain-injured persons is even less.

For example, in the greater Houston area of 3.5 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 875 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.¹³³

Neurologic injury is probably the most costly kind of injury and produces a great need for more organized systems of acute, subacute, restorative, and rehabilitative care. As with burn care, such a system must build on specialized knowledge, skills, experience, and technology with continuity of service and follow-up. Rehabilitation 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.^{120 133}

The data base for the spinal cord injury center program among the 15 regional centers revealed that the intake and follow-up process saved one-third of first-cost dollars, achieved home placement in 85 percent of over 6,000 first admissions, and decreased the incidence of complications and later hospitalizations for complications.²²³ The relatively low incidence and prevalence of neurologic 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 community, 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 pride 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 heads 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.

Conclusions

A national effort is needed to achieve appropriate emphasis on disability-related basic and applied research, technologic research and development, service systems, education and training, and social understanding. Great savings and increased quality of life would result from improved application of what is already known, but there is a need for substantial increases in research in many subjects. Table 6-1, at the end of the chapter, summarizes what is known and what is needed in rehabilitation research.

TABLE 6-1

Status of and Deficits in Rehabilitation-Related Research.

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 injury victims. Long-term institutionalization of able-bodied young adults who could be self-sufficient is the poorest possible solution, but it is the most frequent one today.