Rehabilitation

Illness and trauma that lead to disability or functional loss can lead to an individual's need for a changed lifestyle to accommodate his reduced level of ability. A stroke, for example, can lead to partial paralysis; chronic arthritis can result in the inability to stand or to use one's hands; an automobile accident can cause blindness or can result in an individual's confinement to a wheelchair. To retrain someone who has experienced any of these incidents requires a rehabilitation team.

Through history disabled individuals have been ridiculed, sheltered, offered care, taught to fend for themselves, or killed. The ancient Greeks killed children born crippled. In the Middle Ages the French accorded privileges to the blind. Throughout its history the church provided a place for the disabled to live and receive care. In the sixteenth and seventeenth centuries England established hospitals and passed laws to assist the disabled. The Poor Relief Act of 1601 outlawed begging and provided the means to assist the poor and the disabled. Through these means the disabled became less dependent upon public assistance and learned self-sufficiency. Almshouses were established to house and treat the infirm and this idea was brought to the New World. Pilgrims built almshouses in Boston in the 1660s.

The influx of wounded and maimed soldiers during World War I added impetus to the rehabilitation movement. In 1918, the U.S. government initiated a rehabilitation program for disabled veterans of the Great War. The aim was to enable the wounded to find jobs, so physical aspects of rehabilitation were stressed with little emphasis on psychological ramifications. The program was advanced following World War II to include the psychosocial aspects as well as the physical when veterans were trained for work and received counseling for reintegration into the community. Continued demands for such services have been brought about in this century by industrial accidents, auto accidents, sports injuries, and urban crime. Also, the life expectancy of people in developed countries has increased and with it the probability of contracting a chronic condition from stroke, heart attack, cancer, or other debilitating situation.

In 1947, the American Board of Physical Medicine and Rehabilitation recognized rehabilitation as a physician specialty. A rehabilitation specialist is called a physiatrist. In 1974, the American Nurses' Association established the Association of Rehabilitation Nurses, giving recognition to nurses in the field.

Rehabilitation of the chronically ill or injured individual does not stress cure, but focuses on training the individual to live as independently as possible with the condition, taking into consideration that the condition may change for the worse over time and the disability progress. This means that physical training must be accompanied by shoring up the individual's psychological outlook to accept the condition, accept society's lack of understanding or even rejection, and still to attain the maximum degree of autonomy.

Rehabilitation begins with the assessment of the patient's needs. An individual who was right-handed may lose the use of that arm and need to be trained to use the left hand for writing and other functions that his right arm normally accomplished. Such training consists greatly of iteration, the repetition of simple movements and acts to establish the nerve pathways that have not existed before. Mechanical devices requiring fine degrees of eye-hand coordination force fingers to maneuver in ways unaccustomed.

Patients are encouraged to take advantage of mechanical aids on the market to ease their lifestyle. Opening a jar with one hand, for example, is easily accomplished using a permanently mounted device that grasps the lid while the patient turns the jar. Doorknobs can be replaced by levers. Counter tops can be lowered and extended to provide room for the wheelchair patient to work or eat from them. Handles make getting into and out of a bathtub possible for the elderly or disabled person. Lighted magnifiers provide the means for the visually handicapped to read or carry out other tasks.

Modifications to automobile controls may enable the injured person to drive, thus divorcing him from the need for transportation to be provided. A ramp may need to be constructed to allow his wheelchair access to his home. The wheelchair-bound individual may need to relocate from a multistory living facility to one that is on one floor or one that has an elevator. Even carpeting must be evaluated. The person in a wheelchair may have difficulty wheeling across a deep, soft carpet. A more dense, firm floor covering can save energy and time.

Many injured patients can be rehabilitated by fitting a prosthesis, an artificial limb. Once the body has healed from amputation of the limb, the prosthesis can be fitted and training begun. Muscles that control the movements of the artificial limb must be trained to respond in a way that moves the prosthesis naturally. This requires seemingly endless repetitions of muscle contractions to afford effortless control of the prosthesis.

While physical training progresses, psychological counseling seeks to instill a value of self worth, to counter depression, to reassure the patient that he will be able to function adequately in society and in his career. The initial reaction to a debilitating injury or disease is one of anger at having been so afflicted and depression at the loss of function and freedom and fear that former friends will shun him or that family will exhibit undue sympathy. Counseling seeks to counter all these feelings and bolster the patient's confidence in himself. His changed station in life, losing function because of a stroke or being confined to a wheelchair because of an accident, will be jarring to his coworkers and friends, but usually they will accept the new person and adapt to his requirements.

Beyond the patient, his family also will require counseling to explain the patient's status, his limitations, his needs, and the family's optimal response. Coping day in and day out with a seriously handicapped family member can be grueling for the average family. Assessment of family attitudes, finances, and acceptance of the patient is crucial. The burden of caring for the patient may fall upon the shoulders of one member of the family; the wife, for example, who must care for a severely handicapped husband. Unending days of tending someone who requires close care can be physically and psychologically devastating. However, most family members can carry out their tasks and provide care if they receive some relief at intervals. Rehabilitation, therefore, also may include arrangements for a home health aide part time to provide personal time for the patient's caregiver.

Rehabilitation, therefore, far from merely providing the patient lessons on controlling a wheelchair or learning to walk on crutches, must take into account his environment, his mental status, his family's acceptance and willingness to help, as well as his physical needs. A replacement limb will never achieve the level of function of the original limb, but the prosthesis can serve adequately given sufficient training.